Q&A from YOUR listener submissions

HBP.EP.018.Video

Preston: [00:00:00] Dude, so I leave tomorrow morning to LA for the marathon. 

Margaret: For the full, right? It's a full marathon. The full 

Preston: thing? Yeah. All 26.2. Are 

Margaret: you gonna qualify for Boston? 

Preston: No, I don't think so. 

Margaret: You're like, I'm gonna get Shin Flex and break my leg. 

Preston: I said it as my goal when I first started, and so the thing about like Boston qualifying that I learned last week is that you have to be like a couple minutes under the standard.

So it used to be three hours, which is like. About seven minute mile pace. Mm-hmm. It's like 6 58 or something. And I was like, okay, I, I think I can do that. I ran my, my long run 18 miles and like 7 0 5 pace, so, you know, like super shoes. I bought like the alpha flies with like carbon plated almost illegal shoes for my amateur question.

Margaret: I'm not gonna make running my whole personality. 

Preston: Yeah. You should see the gels I have too. They're, they're disgusting. But, um, 

Margaret: continue. 

Preston: One of them is, one of them is like banana flavored, which like, why would you, did you buy 

Margaret: it? I did. 

Preston: It was why speak as if it was like, it was, it was a variety pack. [00:01:00] I was like, who put banana in here?

Margaret: Uh, should we say what the episode's about before we continue talking about running? 

Preston: Oh yeah. So today is a very special episode is our q and a episode. So we're back. Yeah, that's our first 

Margaret: ever one. Mostly 'cause people blow up my Instagram questions every time I put something on the podcast on there.

Some of them don't fit into a category, so we're gonna try to answer them now. And I think this, well, it's actually our writing episode 

Preston: with a brief intermission to go over q and a. 

Margaret: Wait, what? 

Preston: By writing, I just mean we're gonna talk about my marathon. 

Margaret: Oh, right. We're just gonna ask Preston questions.

Talking about Boston Qualifying 

Preston: yet, I've, I've, I've got the bug where I have to tell everyone that I'm training for a marathon. And you're in 

Margaret: a run club. 

Preston: Yeah. 

Margaret: You're like's my chasing product twice. 

Preston: I show up every now and then. You're beyond the run club now. 

Margaret: Better than the run 

Preston: club. I just like, there's no formal participation, I guess.

Margaret: Do you know, Preston, you weren't on yet? I, my, the camera is no longer on that stack of books and boxes. It's on a tripod [00:02:00] and I have a ring light on. So we're big leagues now. We're big leagues. 

Preston: I, I can see it. You look professional. 

Margaret: I look professional. 

Preston: It's got it. And you got a haircut. 

Margaret: No, I did not. It's the same haircut.

Preston: Well, you got a haircut last time. Nope. In preparation. Okay. No 

Margaret: close. Close lies 

Preston: from how to be patient. 

Margaret: So today's our questions, but first we can talk more about running. Um, 'cause I'm also trying to think, I don't wanna do a marathon. I have specifically, I never wanna do a marathon 'cause my family does marathons and that's a.

You're running, not the pushups, but the running videos. I'm like, maybe I should run again because I'm like, I did like running. Should I run again this spring? I don't know. 

Preston: It's kind of liberating, you know? 

Margaret: How, what will you do after the marathon? 

Preston: Um, I think I'm gonna chill out and then probably go back to lifting for a little bit.

Margaret: You're not gonna, you haven't caught the bug. I feel like you're gonna catch the bug. It's gonna like, they're gonna be clapping for you when you come in and you're gonna be like, we'll see. Humanity [00:03:00] is so great. It's time. 

Preston: I think I'll be annoyed if I'm like, close to qualifying for Boston, but don't, and then I'll probably try to do, do another one.

So like, I think realistically the fastest I could probably run is like a 2 54. Mm-hmm. And I probably need to run under two hours 50 to qualify for Boston. 

Margaret: Are you, are you someone who runs, like, I know you ran in college, but for like long distance, are you someone who's like, runs faster than you think you're going to or hits like very close to what you predicted or is long?

Preston: Um, I think I, I'm always pretty close to what I predict. Like I don't, I don't think I'm underselling myself know. You're like, my 

Margaret: body is a microchip. I know what I can do well yeah. And 

Preston: Garmin predicted me at that. I mean, Gar, my Garmin watch can account for the dog that I have in me, but. It can look at all the other factors, you know, so we'll just, we'll see.

We're letting it off the leash Sunday morning. We'll see what it, what it, 

Margaret: let's leash it by Wednesday. 

Preston: Be re kenneled. [00:04:00] So I feel like Margaret, you get way more questions than I do just because you do a great job of interacting with your Instagram stories as like a, a form of collecting information. So I, I'll let you go first and see what questions, uh, you've found so far.

Margaret: Oh wait, we were, we were gonna do something else first though. I wanted to ask because it's our, the time of the year. It is now. And we're also reaching the end of the, like, that we're starting to transition clinical years. So I was gonna ask you, how does it feel to almost be done with your second year?

Preston: Um, honestly, I haven't really noticed. 

Margaret: Like, I think, I think I'm looking forward to having some stability 

Preston: in clinic. Mm-hmm. Which I know can also bring monotony. Also like, I don't know. I, I feel like this, the blended responsibilities has been like more and more blurred for me in residency, at least. What do you mean?

Like, when I went from being an intern to being a PGY two, all of a sudden I was taking [00:05:00] call. So it seemed like there's this like huge step up in responsibility, but like to me, it felt like I was making all the same decisions. I was doing all the same work. It's just I had like one less person to report to.

Margaret: Mm. But 

Preston: I still have to report to people. You know what I mean? Mm-hmm. So there's just, there's just like one less person in the queue on the way of, I'm like, okay. And so like I have a little bit more autonomy like now as a PGY two, but it just, it doesn't feel as quantized as it did as a med student where they're like, okay, you, you're going from like only doing Chy to now all of a sudden you're in the hospital.

Right? 

So now instead of us babysitting you everywhere you go, you can like go places on your own, right. Then after that, and then, and then the next big step I think was you can hit prescribe on a medication. Mm. But since then, it's kind of all this, all this feels like this, like long train of work. And I don't, I don't get like, as excited about going forward.

Also, I, I don't know. Unlike the podcast. Yeah. No, no, seriously. Um, the podcast is fun, [00:06:00] period. I like. This is cool. I will say all this, uh, aside, dear listener, I'm a bit jaded with residency right now. Like, I remember just like sitting down, I'm on an inpatient psych ward right now and I was just like so annoyed with like the regular of life.

Like I feel like so much of what I do is just like monotonous, repetitive, bureaucratic, and. Drawn out, you know, like the amount of times you sit through, like these like redundant meetings where people p pr on about like nothing that's like necessarily like helpful or pertinent. And then like the highlight of your day might be like a 30 minute patient interaction where you go back to becoming like a slave to documentation.

Mm-hmm. I'm like, oh, okay, I get to go do this in the outpatient setting now too. Like, I don't know, I just don't, I don't feel excited about that. 

Margaret: I'll say I'm biased, I'm. You know, I'm biased and I like outpatient. I feel like I liked third, third year was my favorite year of residency. I [00:07:00] mean, maybe fourth year.

'cause there's just more chill time and you get to like hyper specialize. But third year I felt the most like I was like their doctor. And also then you get to start having, I know we've talked about this, but I think even more so in third year, where you have patients you're seeing every couple weeks and you really know your therapy patients like.

I mean, I've had patients where, like during our last session, I like teared up because of how like connected I felt to them and how much like I think our work was meaningful to them and to me as a trainee. 

Mm-hmm. 

And I, I think you have that ahead of you. I, I'm not a huge, impatient person, so. I also felt that second year, 

Preston: I don't feel that connection when I'm filling out like the order of protective custody or Baker Act on someone who's like basically telling me that like this, like car environment is like the worst thing society's ever created.

Like, yes, I, I think they're sick and that this is like the important thing for them, but like it doesn't feel good. Mm-hmm. You, [00:08:00] I think I have gotten some glimpses of that where I've. We have like one longitudinal clinic like once a week when I've had some triumphs there that I'm like, okay, I, I see why I would like this.

And I've actually had times where I was tired and didn't wanna go into work, and then the longitudinal clinic like turned it around and I was like, oh, wow. They remembered things that I said and it's, it like changed their life or they were excited to come back and tell me things. 

Margaret: Mm-hmm. 

Preston: Mm-hmm. Like I had a, a patient wanna show me like a photo of their daughter and.

If you're like the third person in my life I've showed this to, it's like, wow. Like what a, what? A hundred. That was 

Margaret: my first Just 

Preston: kidding. Yeah, it was, it was like the father, the grandparents, and me, 

Margaret: and me Preston. 

Preston: Yeah. It's like, wow, like this. I'm, I'm like in that circle of people that you wanna share things with.

So, so that, that's, that's cool. And it's energizing and rewarding. [00:09:00] So maybe I won't be an impatient person. I thought I was. It's like the full of the hospital, but 

Margaret: who knows Margaret, you're gonna be a fellow next year. How does that feel? Um, 

good. It feels good to be a fellow. I think finishing residency is exciting.

I think I would be feeling more feelings about it if I wasn't staying in town where I am and, uh, going to be around a lot of people I already know from residency. Mm-hmm. I think. I always cry at graduations even when I'm like, f this. I hated this. I'm like, you know what? Actually I didn't hate it. Um, so yeah, I'm thinking a lot about how do I like transition my role as outpatient chief and like I.

How do you think about handing over that role to the next person who will have it and help there? Be positive, kind, and then also thinking about like handing over your patients who you've really connected with and trying to make that as smooth as possible. And also kind of giving them a transitional object.

So like [00:10:00] how do you reinforce that the relationship mattered for both of you? Mm-hmm. And give them something to hold onto because it is a type of, I think, death when you are doing weekly therapy, at least in the psychodynamic lens. And then at some point you stop seeing them, whether that's because the work is done, they're moving, you're moving to a different stage of life, whatever.

And, but that's, that's hard. I definitely feel very connected to my patients that I see every week. And I'm trying to think about how to end well, which I think is a really beautiful question, but a hard question in psychiatry. 

How do you stick the landing of residency? Yeah, I mean, I guess 

kind of how do you stay with the feeling of it and how do you be thoughtful like, like any graduation or ending of something.

What is 

that feeling? Is it nostalgia for you? 

No, I [00:11:00] think it's just, I've been in therapy before for, I've had some of my therapy patients for two or three years and like mm-hmm. We've been through a lot together in their life and in my life as a trainee, and I've had that as a therapy patient myself. And I'm just so aware of how important it was that my therapist and when I was in med school ended that therapy.

Well. 

Mm-hmm. And, 

and I, and so I wanna be thoughtful. Of being present to that and using like, instead of checking out and going to the next stage, kind of being like, I wouldn't do that probably anyway, but thinking of like, how do I make this ending, not just feel like for that person, like how, how do I reinforce what we've done together and help the story come to the end of its narrative arc in some way.

Preston: Gotcha. So you needed to dramaturgically make sense 

Margaret: dramaturgically that I, as I was saying, that I was like, I am, I was like, I, I am sounding like I'm been in a [00:12:00] psychoanalytic fellowship this year, and 

Preston: that's the theater of your life. The, the final act has to close in a satisfying way, so the audience stands up and laps.

In class. 

Margaret: I dunno, like have you been in therapy where it ended, but it was like really, really important and good meaningful therapy for you. Like it's just, it's like a really, it's a gift. It's like a privilege to have been mm-hmm. With someone in this. And I think ending it well can, if you don't end it well, it's not that it ruins all the other work, but I just think ending it well can really help almost like seal in that goodness you worked on together.

Mm-hmm. 

Preston: Um, I've, I've been on the receiving end of therapy. That ended well. I I have yet to, I'm only like six months in or, or I guess eight months into like my longitudinal clinic. I have yet to graduate a therapy patient. I've had some just kind of ghost me, but, and if you guys wanna come on the 

Margaret: podcast 

just 

Preston: Yeah.

Hurts my feelings a little bit. Um, that's fair. 

Margaret: We've all been ghosted by patients. No, I think, 

Preston: I think like good closure. Yeah. Is, is something that feels [00:13:00] nice. 

Margaret: All right. So shall we do questions or, mm-hmm. So I had the first one, a question we got on Instagram, and I'm gonna not, I didn't write down people's names for this 'cause I'm realizing sometimes people don't want their names attached to these.

So, um, the question I picked for our first one is, can you guys talk about managing academic feedback in a productive way? 

Preston: Do you, do you want me to answer or You can answer? 

Margaret: Um, I can answer first. Okay. I will say, I think one of the most important things that I learned how to do in med school, mostly because my dad had a good sense of humor and was in medicine, um, was recognizing who are the people you want to be like and who are the clinicians or people that you don't want to be like, and then.

Phil, like letting the people you admire, like letting their feedback really matter, especially if it's constructive. Meaning it's not just vague like you're bad at medicine, like you can't really do anything about that. Um, that's not concrete. You can get better at [00:14:00] medicine, you can get better at medicine.

Yeah. Period. Podcast over How to Get Better At Medicine is the next podcast. Um, but then like. So doing that for your people who like really inspire you in healthcare and you wanna be more like, but then the feedback you get from people who are like, I actually really dislike this clinician. I don't like how they are with patients.

I don't respect them intellectually. That becomes the question of, well, how do I work well good enough with this person and get through this without taking to the core of who you are. Someone's feedback, for example, like. I think I had a surgery attending who thought I was pretty incompetent at surgery, which like, honestly fair, valid.

But also his, he wasn't a psychiatrist at that. Mm-hmm. He wa. Mm-hmm. He wasn't the style. So I was like, okay, I'll get better at performing this, but I'm not gonna take it to my soul that he doesn't particularly get what I'm wanna do with med school. 

Mm-hmm. Um, [00:15:00] so. I don't know if it 

Preston: is necessary to differentiate academic feedback from any feedback in kind of this paradigm of advice I'm giving, but my, my mom had this saying she would tell me she is, um, if one person calls you an asshole, maybe they had a bad day.

If two per, if two people call you an asshole, maybe you have a bad day, but if three people call you an asshole, you're an asshole. And I think that this stands for being in the hospital too. Like the, the truth of the matter is like your results speak for themselves. So if one person says like, Hey, I didn't like your presentations.

Okay, maybe they just didn't like your presentations. Like maybe they're an uptight person, you know, but if the next rotation, they don't like them rotation after they don't comment on a different setting that. The odds are that these, like four people are like all collaborating in this grand scheme scheme to gaslight you.

And just, just to show how [00:16:00] like you just, you just ended up with four different unreasonable attendings, like the odds of that go down and the odds that you just happen to be bad at presenting go up. So I think it's just, it's important to like pay attention to like the F which something comes up. Before you start to give like valence or value to it.

I guess that's, that's, that's really what I do for me. So each, like, no matter how like searing or positive the feedback is, I try to kind of say like, okay, this is just like one grain in, in the bucket and we'll see if the bucket fills up or not. And, and a good example of that is like, um, so, so I have a DHD and one of the ways that like my inattention manifests is, is like, it's like.

Staying like focused on something for an extended period of time is, can be like painful for me. So like, if I like, don't take my medication during the day or something, I, I'll like, I'll fidget, I'll like, want to check my phone or check my [00:17:00] watch or something else. Like, like direct my attention somewhere else where it's easily picked up by something else.

And so I like, I remember as a med student, my preceptor would be like on her laptop, like answering emails while I'm interviewing the patient. And then she would like send me an email. While I'm interviewing the patient so that it would, the notification would buzz on my watch. And then I would check my watch 'cause a notification goes off, I wanna see if it's something important.

It's just an email from her like three feet away, 

Margaret: which is a smiley face. And I'd go 

Preston: back to interviewing the patient. Yeah, 

Margaret: you're doing great sweetie. 

Preston: And then the feedback at the end of the rotation was, Hey, you checked your watch a lot during interviews with the patients and I was like. Bro. 

Margaret: You were like, girl, we both have a DHD.

Preston: Yeah. Like a homie. Like yeah, I could, I could like not check them more, but like, why are you sending me messages while I'm eating the patient? Like, you're not charge checking dog. So, so I remember just being like annoyed about that, you know? Mm-hmm. And so, so I was kinda like, I, I was like dismissive of, of that feedback and, but then I got feedback like [00:18:00] other places like, hey, like I noticed like, you know, even if you're in the bathroom or something, you're checking your phone or one of the social workers complained that, you know, you're, you are looking at your phone during rounds or during like table rounds, even after you presented.

So just so you know, people are noticing. And then I'm like, okay, well. Like, yeah, maybe I was checking my watch too much during that, that session. I could externalize and blame it all on her for emailing me, but also maybe I am being too distracted. Mm-hmm. And like, I took that actually as a sign that like, okay, this is imperfect.

And I went and changed my dose of my medication. Mm-hmm. And also like took, made my own behavioral adjustment. So like, I would not use, I would use a different smartwatch or I'd like change my notifications or something else. So I would like set up barriers to alter my behavior. So. Also recognize that there were flaws in the feedback I was getting, but as it started to stack up, there was validity to it.

And then I made change, I guess. And I think like that kind of, the reason why I shared all those, like personal anecdotes is because I think that's a good model to approach academic [00:19:00] feedback. 

Yeah. 

You know, it's, it's all just evidence and you, and you just decide what you wanna do with that evidence. Yeah.

Margaret: I, this is something people will say, but I like, as I get further. As a chief, as I get into the middle management role, I think there is there On one hand, being able to identify like mistreatment, I think can be hard for people, especially when you go into medical school and if you're straight from college and you're like having imposter syndrome.

If, if that's a thing, you're, you're doubting yourself, you're having anxiety, you're in a really weird, hyper monitored way of training. Mm-hmm.

Being able to, to know that some of that is causing anxiety in you. 'cause it causes anxiety in human beings. Mm-hmm. And at the same time, there's a lot of things that can be made use of, even if, even if the person is like someone you don't wanna be like at all. Or like it's not constructive or it's not a pattern that, it's like asking that [00:20:00] question of, can I make use of this in any way without beating myself up with it, I think is a, it helps me.

Hard rotations also a lot. 

More, 

I don't know. Beneficial for you. 

Preston: Yeah. And to your point of like, how can I use this to be, to benefit me? I think one of the best lessons I learned about taking feedback in academic settings is to, to literally just take it. So I know we all have this compulsion to explain why something happened the way it was.

Oh, sorry for not, sorry for checking my watch. I have adhd, I have all these problems. Like I, I just shared none of that with that person. I just said thank you for. And I'm really glad it did that, even though I had this kind of compulsion to explain, explain myself away, explain these things. I, I don't think it, it just necessarily helps.

'cause the feedback is an observation that they're making. 

Margaret: Right. 

Preston: And you don't need to, to try to explain to them why their observation is justified or unjustified. Mm-hmm. It's just an observation. So I think it can be frustrating [00:21:00] for people trying to give you feedback for you to kind of explain it away or add all these caveats to it, even if you're trying to like say why your intent was good.

So. Unless there's like legitimately a mistake. Mm-hmm. I, I usually just try my hardest to just say thank you, I'll think about that. Or like, I appreciate your input. Mm-hmm. And just keeping it short goes goes a long way because taking feedback can be really hard. Yeah. Yeah. And. As I got into residency and started giving people feedback, I noticed the most challenging ones were when I tried to like give a comment and then all of a sudden I like, I can't get a word in because they're explaining all these other things as to like why.

Mm-hmm. Like my observation was like inaccurate or something. So, 

Margaret: yeah, no, I think those are being on 

Preston: like the student side and the resident side, I've seen that like it goes over better for me if I just take it in Same way when you're kind of like giving it to somebody. 

Margaret: Yeah. I think also what you learn from the resident side is like, how do you make this digestible for someone as like a [00:22:00] student?

Um, that like there is an art to giving constructive feedback and it's a skill and not, and you have to practice at that. And I think it'd be intentional. I think there's some people who are naturally good at it maybe, but like mm-hmm. Being able to attune well to the person trying to learn from you. Like what's useful to them, what do they want to learn, what are they motivated by?

And then like. Not being conflict avoidant, but be giving like someone eight critiques on something is like not, they're not going to be able to take all that in mm-hmm. At once. And nor is it helpful. 

Preston: And their only takeaway may be that they failed. Exactly. Yeah. It, it feedback is an empathetic activity.

Mm-hmm. Very empathetic activity 

Margaret: for people early in their, like med school. I like early in residency, this part does get a lot easier, like. I just, I think of third year me of med school versus me now. And like I have so much more capacity now to be like, oh, I am kind of bad at that. Okay, how do we work on it?

Whereas I think when [00:23:00] you're early in your career, like I had failed a couple tests in my first year of med school and like, I think that made me very like anxious and nervous to be, to prove to myself that I was smart enough to be doing what I was doing and mm-hmm. That just if you feel that way in med school, I do think it gets a lot better.

'cause you get reps under your belt and you're like, oh, here are my strengths. And they grow. Mm-hmm. And you see them and other people see them. But the early parts of training are hard 'cause you just feel like a fish out of water. At least I did. 

Preston: Yeah. You haven't poured the foundation. Mm-hmm. And, and like the concrete hasn't dried yet on your, like the stability 

Margaret: of your yourself in medicine.

Okay. Good question. Hopefully we help 

give us feedback on it. Yeah, I hope so. 

Preston: Yeah, please 

Margaret: give us, there's people this, 

Preston: whose entire career is just like analyzing, like how to give good feedback and everything with trainees. 

Margaret: But Psychiatry's made me so much better at that. 'cause it's just like, literally you'll have people watch your interaction with someone and be like, why did you say that?

Preston: [00:24:00] Yeah. No, I, I. The best. Some of the best feedback I got as a med student was like on my psychiatry rotation. It, it was, it was pointed, it was actionable, it was without judgment and it was like helpful. Some of, I still use like, um, my last, last part, my feedback one time I walked out of a room and the resident said like, Hey, I noticed you asked a lot, how'd you feel when this happened?

How'd you feel when that happened? How'd you feel about this? And I was like. Yeah, like I was trying to kinda like get at their emotions I guess. And he goes, yeah, well we're on like child right now. And, and like kids struggle a lot with articulating their emotions and like that's kind of a tall order to ask someone to be like, okay, what was I thinking?

And then how did I feel about that? And what emotions are those? And then name those emotions. So maybe just ask them like the random thoughts that we're going through their head. It's easier to produce a thought than it's to produce an emotion. And I was, holy crap. You know, he like literally looked at the words I was saying.

Okay, sorry. There's. There's a battle going on right here. 

Margaret: Someone gave bad feedback to actually attack was like, you're a dump. [00:25:00] You gotta get outta my house. 

Preston: She was like, Bing, bob, boom, bang, boom, Pam. 

Margaret: How long You wouldn't understand. 

Preston: Yeah. But, but anyways, like yeah. I was like, okay, I, I can follow that.

Alright. Yeah. 

Margaret: Um, well before we go to the next question, we will be right back after this quick break.

Preston: Um, I have one. This is submitted to the podcast page. Good luck on this journey, guys. Great conversations from two very inspiring doctors. 

Margaret: That's it. That's it. 

Preston: That wasn't a question. I just wanted to hear it. No, I'm just kidding. Also interested in psych would be amazing if you could address some of the fears or negative thoughts surrounding psych residency and exposure to mental health training situations and how to combat them.

So I feel like you started the episode you're talking about. Yeah. But you get, you go. I'll, I'll happily go into that because, because I'm already feeling drained. Um, [00:26:00] one of the, the first conversations that I had, um, when I was thinking about psych was worried about it was like, how do you keep from taking work home with you because you do deal with a lot of despondent situations and.

Margaret: Just like emotionally draining interactions can be really hard. And

I would say like a part of me got like used to it and callous 

Preston: and I didn't like, like that. I was losing that I guess. Like I could feel like I'm like writing this note and I'm like, I don't care the outcome of this. And in a lot of ways it can be liberating, but I didn't, don't think that was.

I'm trying to be this like thoughtful, nuanced, engaged provider. So the weird, weirdly enough, I'm, I'm, I'm not gonna give you a satisfying answer here, but hobbies were like probably the single best thing that helped me. In like psych residency and it was like [00:27:00] discovering that I had things that I enjoyed outside of the hospital.

Like I couldn't, no matter how I reframed it or how positive my attitude was or all the things I did, I could not like recharge my battery in the hospital, but I could recharge outside of the hospital. And so like this marathon training we've been joking about for a long time has actually been like so rejuvenating for me.

Because like I would, I'll have like a long run that I'm looking forward to and I'm like, okay, let's be fun. My friend's joining. We're gonna go do this afterwards. And I'll find myself like getting kind of antsy to leave work so I can go do these other things that I have this other like almost like a parallel arc, like a subplot in my life that I'm working towards or looking forward to, like accomplishing things for.

And that was so much more energizing when I left work. So it was like I had something waiting for me at home. And for some people that's your family or your pets or anything else. But, but for me, it was creating like, kind of like that hobby or something I could express myself in. So [00:28:00] I, I like, it's, it's like when someone asks what's the best way to, um, become healthy and lose weight And the answer's always just like, eat well and exercise.

Like it's, it's simple and it's that hard. I guess. You have to find something that you, like, you enjoy outside of the hospital. It's something that like gives you identity outside of medicine. 

Margaret: I think my answer to this would be, I guess, twofold. One would be the less allergic you can get to your own imperfect human responses, like the better.

So if you are for this listener, not for you, um, if you are feeling life despondent or you're feeling like, I don't really like this patient, or like, I'm annoyed, I'm frustrated, I'm angry, I'm sad, I'm irritated. I think there's a secondary kind of emotional response that we often have, which is to say, I shouldn't feel that way, especially early on [00:29:00] in training.

I think it's like, I shouldn't feel this way. Like good doctors care about their patients all the time. Good psychiatrists always are perfectly empathetic. Other people aren't struggling with this the way that I am, and I think primarily and a psychiatrist, like and having a lot of friends in healthcare.

Other people are struggling with that like kind of empathy gap, if you wanna call it that, although I don't think that's accurate, but so I think that there's a lot of hoops that we jump through in the formation of applying to med, being pre-med, applying to med school, getting into a residency that teaches us we have to disown a lot of parts of ourselves because we are marketing ourselves as this perfect, caring, smart doctor.

Um. And we internalize that, and I think that makes pain even harder. It makes grief even harder. It makes that sense of loss or corrosion of belief in the system harder when we're like, and you're bad because you're having that feeling. Um, mm-hmm. So. That is what I would say. And then the other thing I will [00:30:00] add besides I agree with the hobby and having other stuff.

I was laughing 'cause I was thinking about that video you did a couple years ago that was like when you rotate with psych and it's like he has like a plant and like a psych is always on side quests. Um. 

Preston: Yeah, this, I'm wearing the same shirt. Are you? Yeah. As before that video. Yeah. 

Margaret: Um, the other thing I was gonna say, and I was saying this when we, like, we're in the point of the year where we transition from current fours to the upcoming PGY fours for chiefs.

And I was telling my friend who's gonna be a chief, like when you're working in the hospital system, when you're working in psychiatry or healthcare in general, there can be a lot of things that cause moral injury and that are really slow to change. But if there are areas you see, even as simple as like planting a community garden or I like added a lecture series that I like just annoyed a bunch of faculty and was like, would you volunteer one hour of time to teach us on this or this podcast?

Honestly, for me it's like something that you can, you have a good chance of really being able to [00:31:00] like see it change and grow even in a small way can help with that feeling of, I think stagnation and like nothing will ever change because I think that moral burnout can be really tough. 

Preston: You just have to employ your mature ego defenses 

Margaret: and be okay with your not mature one 

Preston: Sublimate.

Practice altruism, humor. Find a sense of humor. 

Margaret: Yeah, 

Preston: there, that's all it takes. 

Margaret: Get a giggle in there every once in a while. I do think because they asked about psych compared to other specialties, you have to redefine what a win is and psych 

absolutely. 

And I think that's cool. I think that's great. I think it makes, having to do that with my patients makes it me better at it in my own life.

But it can't be like we cured them of their infection because like you're not gonna have that often in psychiatry. 

Preston: Yeah. Here, like the medical model that we apply is like, if I cure your depression, that's a win. Like, I don't know, dude, I think the win is like, you had a shower today. Let's start with [00:32:00] that.

Yep. Yeah. 

Margaret: Yeah. 

Preston: That helps Changing. Changing what the goalpost 

Margaret: is. Mm-hmm. It's a big difference. Okay. Cool. So next question. 

All right. Ready? 

Mm-hmm. 

I know we did an episode on coping, but this one is more specific than in residency, which is coping strategies to survive med school. From a psychiatric perspective, I think there's, I thinking of the timeline in med school, and I feel like it's like.

The first year, year and a half, two years of like lectures and studying for step one, the being judged on clinical rotations and not being around your friends. 'cause suddenly you're all in different rotations. And then the anxiety of fourth year and, and or the excitement, anxiety and disappointment of the match.

Um, so I feel like all three of those, you can use similar coping skills, but I feel like the first couple years of med school, the thing that helped me the most was like. Reading a book on time management, [00:33:00] like how to like do the pomodoro. I know everyone's gonna hate that answer. Yeah. But like, it just feels like it was endless.

And I was like, I don't give, I knew I wanted to go to psychiatry when I started med school. I was like, I don't care about histology. Like, that was not my dream. I don't care about this. So like how do you dose it out? How do you add the parts you do like in there, um, for third year? I don't know that I have any tips off the top of my head.

And then for fourth year, like I feel like how, depending on how your school does the match, like having a coping plan regardless for time after you find out whether you're disappointed or really excited so that you kind of have a cope ahead, like depending on what emotions come up with the match. 

I think that, um.

It's probably the best way 

Preston: for me that's, that was for me, the first two years at least. Like, [00:34:00] and I didn't use Pomodoro, but I would create like arbitrary rules that I would follow, almost like religiously, like it's 8:00 PM the night before an exam. I'd be like, no more studying aloud like you're gonna make dinner and you're gonna like watch TV or something and I need to like follow those rules.

And that's not to say like, oh, that doesn't mean I didn't study that before the exam. Well. No, I knew that rule was coming up, which is why I studied really hard earlier in the day because 8:00 PM is my cutoff regardless, and I had to respect it. So by do, by like creating those walls for myself, I could like allow for unprotected time because when you're kind of just like allowed to study in perpetuity, it can, medicine can dominate every part of your life, so you have to find a way to cage it a little bit.

Margaret: The other thing I'll say with this, just since we're in the post like Covid era hybrid, when you can go to lectures and stay in that habit, stay in the habit of getting up and getting dressed [00:35:00] and leaving your house and socializing. I. And wearing shoes. I don't know, like at this point with med schools, like how much has hybrid zoom options and stuff.

But I think if that had been true when I was in my first and second year med school, I would've been a goner. 

Preston: Yeah. Or Or even if you're not gonna go to the lecture. Yeah. And you're using third party resources, make a plan for the day and create routine. So you still have to be outta the house by eight o'clock or something and then go, and then if you're going to a coffee shop just to watch sketchy.

Or just to like washboards and be on, do that, but like, you need to have your own classroom or a place that you'd go that gives you routine. 

Margaret: Any I any thoughts on coping with the match? 

Preston: Um, good luck. It's such a weird thing. No, my, my friend actually, he, I had a friend who matched pretty low on his list and he was kind of upset about it, and he like, brought up this paper.

He was like, yeah, well, the thing that's helped me the most is that. They did this survey of resident happiness, like around the [00:36:00] match. Mm-hmm. And then like right before residency, and then like six months into residency and there was a huge gap around the match. And then the gap like almost completely leveled out six months into residency.

1. Everyone, whether you, no, but like whether you were elated about where you're going, then you kind of realize like, oh shit, I still have to go through residency. Mm-hmm. Or whether you're really disappointed about where you're going. You're like, wait, I still get to be in residency. Everyone kind of comes out to be in the same place.

Mm-hmm. Yeah. Yeah. 

So he was just like, yeah, like, so these feelings are temporary that I'm having, and we're all still going to the same destination. So I, I, I think that was a great way to cope with it, actually. 

Margaret: Yeah. 

Preston: Maybe it was a little bit of intellectualizing, but ultimately just saying like, this is temporary and I can be disappointed and excited and try to hold space for both of those feelings.

And it's, it's really hard, especially, and, and for the, those med students who have parents that have certain expectations, I, I don't have good advice for that. It's just, it [00:37:00] sucks. Um, my, my parents were just like. Why are you going to med school? And I was like, I don't know, I want to. And they're like, okay, have fun honey.

So I, I never felt like any external pressure was always self-imposed. This all helps with self, self-imposed problems, I guess. 

Margaret: Cool. Okay. I'm done. I'm done talking about that question now. 

Your question now. 

Alright. 

Preston: So, hey guys, love the pod. 

Margaret: They're like You included the ones with praise you. Like first compli comment, compliment as a treat.

Preston: Comment wan to let you know that the eagle sound you used in the most recent, recent episode, 

Margaret: can we play it here? Making through winner 

Preston: SAD 

Margaret: editors play the eagle sound that we thought was an eagle sound. 

Preston: It isn't actually an eagle sound. It's a red-tailed hawk. I know that American media has led us to believe that is an eagle, but the sound is not.

Eagles actually sound very cute and would recommend looking it up. Smiley face. I know you guys strive for medical accuracy and excellence, so I hope this extends to bird sounds too. Thank you, Holly. Pod and Bird Lover. So can we, I, [00:38:00] I made sure to not look at what an eagle sounds like. So can we look, look up an eagle sound?

Margaret: Are you able to play it that we can hear it? 

Preston: No, I'm gonna YouTube it really quick. So there's a bird sound effects.com. 

Margaret: Sponsor us. 

Preston: Okay, here you go. Okay. Lemme know if you can hear it when I play a sound. Okay. 

Margaret: That 

is so different.

That is pretty. I was used to,

it's.

I did not expect any piece of that, so I, 

Preston: I don't have a question after that. I just wanted to hear what a [00:39:00] bald eagle sounded like. 

Margaret: We're gonna, we're gonna sit in silence in awe for two minutes, and pair respect Preston's and Alias in mindfulness again. 

Preston: Did you know that one of the reasons why, um, DDT was outlawed was because of bald eagles?

Margaret: No. Why was it killing them? 

Preston: Uh, yeah, but indirectly, so I guess, um, the DDT would, it would bind to calcium really well, so, oh, they would, it would run off of the farms into like rivers and streams, and then the, it would get absorbed into the fish. It wouldn't affect the fish, but then when the bald eagles would eat the fish, it would weaken the structure of their eggs.

So when they would like lay the egg, they would just shatter right away. And then the bald eagle population was getting affected. 

Margaret: Dini. You know how there's that thing that goes around online that's like they're putting birth control in the water and it's making the frog? I'm like, I'm 

Preston: chemicals in the water.

Turn the freaking frog. [00:40:00] 

Margaret: It's making the eagle. Infertile was actually real. 

Preston: The damn pesticides that they're putting in the water, making the eagles. I don't know why I'm saying this, like in an ironic accent, and it's actually what happened. They put pesticides in the water and it made the eagles infertile.

Margaret: Oh, something to think about. Listeners, something to think about.

Preston: Next time you shampoo your hair and you're thinking about the ozone layer, just think about your. Eagle fertility in your community, 

Margaret: constantly, constantly thinking about eagle fertility. Um, I don't really know how to transition from that. 

We can just keep thinking about those. 

No wonderful birds. No, I don't think 

we should that to our audience.

So

Preston: did you have a, did you have another question? 

Margaret: Yeah. [00:41:00] First of all, how dare you. Second of all, um, the question, okay, this is my last question for the episode approaches to patients who blame everything in life on external factors. 

Hmm. 

That was the only context in the question. Um, 

I would say, do you wanna answer first or do you want me to answer?

No, you can answer first for this one. 

Preston: I, I was just talking about this with a patient this morning. Mm-hmm. They, they weren't tr struggling with blaming things on external factors, but their, um, partner was. Mm-hmm. And the, the advice I gave to the patient, which is what I'll give to this, um, listener or or writer of the question as well, is that you can't move a ship.

Like you can't force someone to see anything they don't wanna see, but you can be a lighthouse. Hmm. So you just kind of have to remember your control. Mm-hmm. And I know why. I guess I do know why. Because, because it would feel righteous and [00:42:00] just we, we have this desire to force people to see why they're a part of the problem or why they're wrong.

Mm-hmm. 

And you have to understand that no amount of reason, no amount of yelling, no amount of arguing until you're blue in the face, is gonna make someone see why they're wrong if they don't want to see that, or if they're not willing to right now. So that's something you just have to kind of let control of, let, let your like desire to control go.

Yeah. Yeah. 

In that regard. And so honestly, once I did that, it, it was, it's pretty liberating with people that externalize a lot of stuff. 

Margaret: Mm-hmm. 

Preston: And then you can say like, okay, I can just, I can still be like a beacon of truth the best I can and kind of offer my opinion mm-hmm. 

Margaret: Like 

Preston: a lighthouse would, but I, I can't do whatever the ship's doing in the harbor.

Margaret: Yeah. 

Preston: And, and I can say like, I'll be standing here if you choose to come back, but if you wanna go out again, okay. I'm not gonna, I'm not gonna lose sleep [00:43:00] over it. So I, I think like, I, I found that when I'm around someone who externalizes all the time mm-hmm. Trying to like pin them down harder, just makes things worse.

And you just kind of have to almost like, take a step back and like protect yourself. 

Margaret: Yeah. I like, I, I totally agree with. I like that metaphor also, or that saying, I think 

the other thing I think about timestamp 

Preston: that Margaret liked, my metaphor 

Margaret: happened once in season four. I use a lot of 

Preston: metaphors and Margaret never says that.

Margaret: Well, this was a serious metaphor. I like your serious metaphors usually. Um, I think you have that for some people. I think thinking about like what. That they weren't effect like that they weren't gonna be effective in something. Because I think externalizing can come from a lot of places, but one of the places it can be is like I haven't had experiences of agency or I [00:44:00] haven't been taught how to both be compassionate to myself and seek change in a difficult environment.

And that can happen for a lot of reasons. Certainly we talk about like helplessness in the trauma world when there is. When someone's been through a lot, very early in development that they literally could not escape or impact from happening to them. And so I think that's part of it. When I think about like Covid, right?

Like I think all of us felt sort of out of control and unable to impact things during that time. And maybe still now for a number of reasons. And I, I do think there's something about practice of. Being able to show yourself and like respect your own strength and your ability to change things. This may be naive, but I kind of think everyone wants to feel strong.

Mm-hmm. And it doesn't feel good for people who constantly externalize necessarily. Like they don't feel effective. Like they feel like if everything is not in them at all, they [00:45:00] can't change anything. Like that's a very helpless situation. But they still have to be ready to hear it. And I think we also have to be creative with our empathy and our ability to sit with and wait until someone's ready to engage in small ways and maybe a different way that they're not as familiar with.

Preston: Mm-hmm. Yeah, and it's, it's hard to be patient for wait, to wait for someone to say like. Maybe there is something different I can do. 

Margaret: Podcast name mentioned, it's hard to be patient. Good thing this episode 19 on how to be, 

Preston: it's like in those movies when like the characters nonchalantly say the, the title of the movie, 

Margaret: we did it.

We did it wrap up. Season one 

Preston: ler, he's really putting together a list. 

Margaret: Is that movie. 

Preston: No, maybe 

Margaret: there's a lot of goodwill hunting. Wow. 

Preston: We, I, I really feel like Shawshank is redeemed at this point. [00:46:00] 

Margaret: Legally. She's Okay. Sorry. This is not a funny bit, and I know that

you were saying something real 

before I derail us. 

Preston: Gosh, this really is the age of Ultron Avengers Assemble.

Margaret: I, I can't guide you. You were saying something real before this. 

It's like we've entered the kingdom of the crystal skull. 

What is that? 

Indiana Jones. 

Preston: The kingdom of the Crystal. Episode two is so funny. I 

Margaret: misnamed your branch of. Uh, 

the military. 

Military, 

I was like, is military the right term? 

And I was like, what was it, what is that movie that I was like, that's you.

And you're like, that's actually like Navy and not, not Air Force. 

Preston: Yeah. So, so we were talking about externalizing, um, [00:47:00] let me see what I was gonna say. Oh, you have to be patient and wait for them. It's like hard to wait for them to say like, maybe there is a difference I can make. 

Margaret: Maybe, 

Preston: maybe this is. Partly in my control, 

Margaret: right?

Preston: And and with that comes also partly my fault. And so like if they can accept both of those things, they can get the benefit of being like, wow, I have some power in this situation, while also accepting the fault. 

Margaret: I think the other part as a clinician with this, and I think this happens so much in outpatient, it happens in inpatient too, but outpatient, just as you get to know someone is like externalizing and being like holding someone who's like you, there must be another medication that'll fix this.

And we can try every medication in the list, but I think as you, at least in psychiatry, like you have to practice getting good at being like, here's what the evidence basis is, which is part of why we do this podcast. Um, here's what we reasonably think it can do. [00:48:00] And that those things integrated with my clinical judgment and my knowledge of the patient getting comfortable with being like.

I actually don't think that a medication change right now is going to help with this repetition with the OCD. I think that we've seen the Lexapro help you a lot, but we need to engage in therapy. Mm-hmm. But that is super uncomfortable and has to be done delicately and people still might get not like understandably upset with you.

And I think holding that and having enough space to process that with supervisors, especially early in career, is really important. Otherwise, you're just gonna be mad. Like you are gonna be mad and it, it'll make sense. You're like, I didn't sleep. I was on call this weekend and I spent 10 years trying to do this and now this person's mad at me 'cause I won't prescribe them the X, Y, Z thing.

Yeah. Like I think it's very easy to get angry. 

Preston: Yeah. Like the, the groundwork that you lay for that moment, when you build insight, it's not in that initial visit. It can be like [00:49:00] expectations that were sent months. 

Margaret: Mm-hmm. 

Preston: Expectations that were set months prior, before you finally get to someone and say like, Hey, like remember I said like this medication will be a part of it.

Therapy a part of, but also kind of your own environment that you have control over is a part of it. Mm-hmm. That's where this part comes into play and a lot of importance comes from introducing a topic early and giving it time to grow and kind of in the background rather than trying to force something at once.

'cause it has, it's be very slow. 

Margaret: I think we have to reckon with our own fantasies of where the field is at as well, like mm-hmm. Like what you said at the beginning of the answer to this question, like it is very uncomfortable to not have a good tool to help someone, and sometimes you just don't in any of medicine, but in psychiatry in particular, and I think to feel not capable.

Like you're not helping and then someone's telling you that you're [00:50:00] denying them something that would help Their suffering is an extremely hard thing to hold. So we are at the end of our question round. Next time we do a question episode for season two, we should do a like hot takes one where it's like you have five seconds to answer this question.

Yeah. 

And then we'll get canceled and the show will be.

Yeah, we really appreciate everyone's questions and feedback. It helps us as a, as we've said, like shape, how we format the show and what's working the best and also what's the most useful. 

Mm-hmm. 

And we put all, I feel like the questions we picked went along this theme that people have asked us to talk more on, which is kind of like have it living in medicine and just the emotional parts of going through training and dealing with being a person in healthcare.

Preston: Yeah. I, I like how this has become alive and we're interacting with the audience more. It's, it's fun to hear everyone's [00:51:00] questions and to kinda get to turn this into a bit of a conversation. I know one thing that. They did, uh, with the Glock FFLs is they did a couple, like live shows, not necessarily, not like in person on a stage, but they have like hosts, like a live session and just kind of answer questions from the chat.

Margaret: Hmm. 

Preston: That could be fun to try as well too. Yeah. So if that's something you'd be interested in, um, please let us know. Alright, well this is kind of fun. I, I wanna do a better job of like finding more off the wall questions too and to kind of like find small things. So like what? This, this is kind of our, our first, first round farming questions bit 

Margaret: F Mary Kill 

would you, 

these acronyms of different things from med school.

Preston: So, um, like always if you wanna submit any questions or, or you have anything you'd like to say, you can come chat with us on, um, Instagram or TikTok at Human Content Pods. You can also message us on how to be patient pod.com. You can all, you can find any of these episodes on my YouTube at it's [00:52:00] prerow or on Margaret's, show her show her Instagram badar every day.

And that's the same on TikTok and Substack as well. Shout out to everyone that left a question today. We kept your names out of it, but also if you have any wins or just like fun anecdotes you wanna share, we'd love to read those as well. We'll try to incorporate that, incorporate that into like more, um, long lasting SE segments.

Thanks again for listening. We're your host, Preston Roche and Margaret Duncan, our executive producer. Are Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Zo. Our music is Bio Ma ben v. To learn more about our program, disclaimer and ethics policy, submission verification, licensing terms, and our HIPAA release terms, go to How to be patient paw.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns.

How do be patient is a human content [00:53:00] production.