Michael: Hey everybody, and welcome back to Doctors Living Deliberately. Hey, Arpita, how's everything going?

Arpita: Hey, Michael. Going well. Chugging along, making it happen.

Michael: Well, great. Well, super excited today to have Dr. Amanda Dinsmore here to talk to us. She is a part of The Whole Physician. Hey, Amanda. Amanda: Hello. Thank you guys for having me on today.

Michael: So great to have you here. Well, you know, we know you so well, but why don't you take a moment to introduce yourself to everybody and tell us a little bit about what you do.

Amanda: Okay. Well, I'm Amanda Dinsmore I'm a board certified emergency physician. I grew up in Oklahoma, did my med school at the University of Oklahoma, did residency at Wake Forest in North Carolina and then relocated back in Springfield, Missouri. My husband is an anesthesiologist and we had two great jobs in Springfield, Missouri, which is close to our family, but also not right up in family. So it's kind of a good, it's easy day trip. I ended up, even before Covid had a lot of burnout issues in the ER, COVID may be relatively something that has provoked burnout in other specialties, but ER docs have been burned out way before Covid ever hit.

So I had my own experience with that and decided, I don't know what I need to do, but I need to do something to just see what's out there. So I ended up doing a fellowship in integrative medicine just as a random, I mean, people thought I was crazy. I thought I was crazy. I just knew if I stayed stuck, I was gonna stay stuck. So I, for the first time ever, I followed no script and just tried something and in it a big recurring theme in integrated medicine is you don't just get to tell your patients to do something. You also have to live that way. And how many of us would never recommend patients live the way that we had been living? And so that was kind of eye-opening for me, and I eventually found coaching. And Pile was also in my same integrative medicine class. She had done the Life Coach school. I had already heard of the Life Coach School from katrina, I had been listening to her podcasts, and so I ended up getting certified as well when I was doing my fellowship.

So I live in Springfield, Missouri now. I work in our freestanding ER which, you know, sees a little less acuity, but it turned into the Covid hub, so I'm deep in Covid, but I'm still working clinically and doing coaching on the side. The Whole Physician is, we are three ER docs, all of who were affected by burnout in various ways, and we are just trying to help doctors with the things that we should have known going into residency and our practices that no one ever told us that would've made a huge difference for us.

Arpita: That's awesome. That's so interesting. So you and two other ER colleagues created The Whole Physician, which is your, kind of your entity and that's a coaching entity. Correct? That you're offering coaching to perfect? So perfect. I said perfect. Well what about that exactly right. I think a big part of what we thought would be good to talk about with you is perfectionism, right? And You know, looking at an ER physician and well first looking back at our training and seeing how we are expected to like do things spot on, exact a hundred percent all through med school, all through residency. That's kind of like, ingrained and burned into our brain. I can see, or I can imagine myself as an ER doctor, having to like work in the heat of it, in the crux of the moment, just like flying by the seat of your pants. When those traumas and things come in it, some of that perfectionism has to go by the wayside. So can you speak to a little bit about that? Like, have you experienced that as an ER physician and how you've had to kind of overcome this overbearing belief that you have to be perfect.

Amanda: I would like to say that we give that up at some point being ER docs, but the problem is we don't. And so it is a miserable experience when everything is your fault. It's not a system problem, it's you missed it. Your Spidey sense didn't kick in. Even if the consultant said, send them home. We're taught you should have fought harder for the patient. You know if you're looking at it objectively, it doesn't make any sense to be a perfectionist in the Er. However, I know that that was my experience and I, I mean, I've been working in the ER for 20 years now and so many of my partners had the same experience too, and it's part of why working in the emergency room, we have 60% of physicians who are feeling burnout. And some of it is this, this feeling that you can't ever succeed in your job and that you're a failure all the time when you go to your job. So if you're looking at it objectively, it doesn't make any sense, but I'm telling you, it is a big problem for us.

Michael: Yeah. And I think for medicine in general, obviously doctors are high achievers and perfectionism runs rampant in high achievers. And so how did you manage to integrate, you know, being a high achiever, being a perfectionist, and still being an emergency room physician who doesn't beat yourself up all the time for things that don't go perfect?

Amanda: I didn't . Michael: Good answer,

Amanda: That's what almost broke me. So here's the thing. Now, some people have been perfectionists their whole lives and a lot of my clients say this, they came from overly critical families and this was ingrained in them long before. But the data would suggest the vast majority of people going into medicine are actually healthy high achievers. And we can talk about that a little bit more. The difference between a high achiever and a maladaptive perfectionist. We enter medicine, you know, first year medical school students as high achievers, but by year two we start leaning over into maladaptive. So there's something about the training of medical school. First of all, you get your white coat on day one. Even the day that you get your medical school admission letter, all of a sudden everybody and their dog is asking you medical questions. You can't possibly know the answer, but they are insinuating that you should know, and you start thinking, well, maybe I should know this, even though it's not possible to know yet. I haven't even gone to school yet. There's that. Think back to like our surgical m and ms. Those things were malignant, just filleting people in public, like a public roasting, those sorts of things... like bad patient feedback. These sorts of negative feedback loops start switching your motivation from an intrinsic motivation of, I know that I'm capable of so much and I wanna see what I can do, I wanna see how many people I can help. That's what we enter medical school with, and it moves to extrinsic motivation. Like, I need to get all of this right so nobody can criticize me. It moves from an intrinsic motivation of I wanna do this to contribute, to fear-based actually is what perfectionism is. It's a fear of criticism and unfortunately we start imprinting this voice in our head that we can't escape our own criticism at some point. So perfectionism, maladaptive perfectionism at least, which adaptive perfectionism that is, that is useful, but we're gonna call that high achieving, that's the intrinsic, the maladaptive, that's the fear of criticism. Fear of failure. That's what is not useful.

Arpita: Yeah. Like what other people are gonna think, what other people are gonna say about me?

Amanda: All this, making points that you've picked up in your head that you're not going to have your own back too, you're going to criticize yourself relentlessly, and you can't escape that. That's what ended up happening to me was this became a voice that I heard all the time. You should have done this. You should have done that. I can't believe you missed this. I can't believe your spidey sense didn't kick in and you didn't know this diagnosable problem was there. Like it was exhausting.

Arpita: Yeah. Oh my gosh. I hear you. I feel you. And my heart is going out that you even had gone through that. And the thing is that so many physicians go through that, right? It's what we're going through and we're scared to say it because we don't think anybody else is going through that. So we just kind of deal with it ourselves, and we continue down that spiral rather than collaborating, understanding like that's what everybody's thinking.

Amanda: It's also why we're judgy of everyone else, because we think that we're getting judged too. You know, I know that like I would send somebody back to a primary care office or whatever, and they're like, I can't believe that she did that and that she doesn't know what she's doing. Then I would do the same thing to them. You know? Like, this is so dumb. I can't believe that they, you know what I mean? If we all could drop that like that would unbelievable.

Arpita: Yeah. Oh my gosh. So talk a little bit about how you started to make a shift with that. Like how you built your awareness that this was what was going on and then moved to make changes. How did that happen?

 Amanda: Well, so I, yeah, I had gotten in a bad place where I was dreading every shift because I thought, well, something's gonna go wrong. Yeah, it will. But I wouldn't be able to escape the own voice in my head or, you know, what I thought like patients families might think, or patients might think, or other consultants might think, or my own peers might think. And when I would, you know, miss something that was undiagnosable at the time, I was relentless with the self-flagellation. I would have a recurring nightmare all the time of like, I couldn't find my patients. I couldn't recheck them. I didn't know where they were. Like this was a common nightmare that I would have. Like I was stuck in molasses and I couldn't get to them. I started breaking out in hives at work, but like no wonder. I was, I was my own worst nightmare. And I didn't know that until, you know, some of the integrative medicine stuff and then some of the coaching. I did not know that these thoughts were optional. And so that was just mind blowing, that like, oh, I don't have to beat myself up. Like I could, I have permission to be human? Like that was huge.

Michael: Can you talk a little bit about that? Because some people may not know what you mean by these thoughts are optional. So can you talk a little bit about that? How are thoughts optional and how did you make that shift?

Amanda: So one thing that I think gets reinforced in ER docs a lot is you are the, the system's broken, but you are the last line of defense for patients out there. And we really are the only place that a lot of people can come to, go to. They can't get in, they don't have insurance. You know? So we, that is true in one way, but making it so dramatic that it's only up to me, there's huge system problems, but I'm still supposed to be perfect. That seems useful, but it was only giving me hives. Do you see what I mean? So now that I realize that yes, this system is not as efficient or as perfect as maybe like I would love it to be. However, I'm just showing up to do the best I can and I will continue to do the best I can and feel good about it. That is such a different way to approach a shift then, oh my God, something's gonna go wrong and I'm gonna have to beat myself up about it for the next three months and not sleep and all of this sort of stuff. It's just, it's the same circumstance. It's the same bazillion people in the waiting room, but I don't have to make it personal.

Michael: Yeah, I think what you're alluding to here is just questioning these thoughts that you have, like everything is reliant on you, everything is dependent on you. Whether this patient, you know, survives and thrives or goes back into the world and doesn't, it's all on you. And just asking yourself, is that even true? Is this really all on me? Is this one interaction, the make or break moment? And I think that's one of the things that coaching has brought into my life is questioning these thoughts that we have. Like, well, is that even real? And so that's interesting that that is kind of what moved things for you? Moved the needle.

Amanda: Well, and the other thing is that you get to keep thoughts if they're giving you the result that you want. If those thoughts were truly making me a better physician, I would keep them every day. But what it was doing is making me have nightmares second guess myself all the time. And my result was that I was breaking out in hives at work and making my entire... I'm just trying to help people, but my life living in that thought was misery. So then I need to change it because the result I'm getting from that thought, if it was beneficial, keep it, but it was not for me. And so while some of it is true, it wasn't serving me to think that.

Arpita: Yeah I relate to you a hundred... I think, I will be surprised if there's one physician who does not relate to you. I will just say it like that. But yeah, I relate. I mean, I stopped practicing clinically. I've talked about that before, and just managing this medical practice my thought always was that if it's not perfect or if a patient has a bad experience, that it's a reflection of us and our reputation. And that perfectionism got to be to a point where it was actually crippling my ability. And for me it showed up as anger. Right? So for everybody, the way it shows up for you, it was so you were getting hives. For me, I would show up as anger. Michael, I'm sure it showed up one way for you or the other. How did it show up for you?

Michael: Yeah, I think very similar to you in anger and frustration. Right? In just feeling very like out of control in the moment and sometimes even just kind of lashing out, right? And so that for sure.

Amanda: Whereas you guys might be reactors, I was an expert buffer and I think that's why it ended up coming out as hives because it was still in there. It had to come out somewhere. But I would come home, I would have a glass of wine. Sometimes I would eat Taco Bell on the way home, like not even that interested in it, but just like don't feel the feelings. Don't feel the feelings. I would watch every episode of every franchise of Real Housewives and literally, I would say, I just need to numb out. So I didn't know what buffering was, but I knew I was just trying to like, numb everything.

Michael: Yeah. For people that don't know buffering is exactly that. Right? Buffering is that just trying to do anything that you can so that you don't feel something so that you can just feel better. Right? Anything to just like, give you that, like hit that you need that just makes you relax and just, just feel better and I don't know that I would say that Taco Bell has ever made me feel better, but good for you.

Amanda: Get me that taco bell.

Arpita: That is a good point too is that, when we buffer, we do something that temporary makes us feel better, but in the long run we regret it later. It makes us feel worse. So you might have a little GI upset from your Taco Bell down the road, and then Michael Hersh can help you. Right?

Amanda: Yeah. A lot of people use food as a buffer to not feel things. A lot of people use alcohol, some people use online shopping or scrolling social media. There's so many things. The point is, though, is it specifically trying to numb yourself and Real Housewives worked very well for me. I mean, it was mind numbing.

Michael: So how do you help your clients like make this transition? Because this can be, this is a lot of work for a physician that has sat in perfectionism for his or her entire life. This is a difficult change. So how do you take people through?

Amanda: It is. And that is why I think it's so critical to be a physician coach is because I've had several clients who had gone to therapists and that sort of stuff, but when they said, I think I might have contributed to somebody's death, or I think this is all my fault, they were just like, it was like a deer in the headlights sort of thing, whereas I've been there and the biggest thing that I can give my clients is permission to be a human being. They for some reason won't accept it from anyone else, and that's been a huge advantage for me also being a peer is like, no, I am your peer. I get it. I know that you want nothing best for your patients and, you are a human and you're allowed to be a human. That is the biggest gift I feel like as a physician, where other therapists and stuff, it just, we don't believe anybody else. Like, I know, but I'm a physician. Like, it doesn't make sense. I'm not saying that it makes sense, but that has been very liberating for my clients of like, no, I get it. I do get it.

Arpita: That speaks a little bit to this, the connection, you know, connection mitigates trauma, right? So these are all traumas that we've experienced, and when we have that ability to connect with a colleague, a fellow physician who's gone through it or maybe hasn't necessarily gone through it, but they understand it because we've all gone through the same schooling and training. That connection helps mitigate that trauma so we can move past it and start talking about it and heal from there.

Amanda: Right. I laughed because I just saw some of my best high school friends last weekend and she was like, my boss always, she's a very successful real estate agent, and she's like, my boss always says, well, it's not lives at stake. It's okay. Like, but it's lives at stake. And it's so big. It is big. And I think that's why we're like, I know, but there are lives at stake.

Arpita: Exactly. Oh my gosh.

Michael: I was just gonna also just mention that one of the other things that I know Amanda loves to talk about is community. And so when you are, you know, when you're saying that physicians are looking to other physicians because really there's no other group. There's no other job. There's no other profession that truly understands the day in, day out pressures, both the external pressures that get put on us by this broken system that you were alluding to earlier, and also the internal pressures that have been basically kind of melted into our own personalities through our training. And I think what you were saying about physician coaching is that it actually has created this community of other physicians that actually just makes all of this okay. And I agree with you wholeheartedly that sometimes just having a community of other people who have been through it or understand the experiences, is such a part of the transformation, is such a part of undoing the perfectionism that we've been talking about.

 Amanda: Right. Well, so one of the things is this, you know, you start to emulate your attendings. You start to emulate the people teaching you, and all that's been emulated is flawlessness. Is the only possibility no one talks about when they missed things. In my ER training, I only heard about near misses. Like, oh my gosh, I almost missed it. And so now even when I talk about my big miss, people are like, oh, I almost missed something one time. We, we are not allowed to be vulnerable and that is so isolating that you think that you're the only person who is a human being in the white coat. But we all are. We just have to be more vulnerable with each other. It would be such a better workplace.

Arpita: It would, and it's also helping foster development of future physicians who are good. We had an instance in our office where we trained fellows and one of the fellows, we had an adverse outcome with one patient years ago. And you know, I think there was a little hesitancy to explain all the details and the fellow was like, you know what? I want to know this because then I can grow and get better. Right? And we have to recognize that we're responsible also to pay it forward, to teach the next generation how to be vulnerable, how to be okay with recognizing that we are all human and make mistakes, and that's how we're gonna learn. That's a huge part of it in my opinion too.

Amanda: Right So into the next thing is that there's four big categories of perfectionism or four tendencies, I guess, where the high achieving is the adaptive, the perfectionism, we're gonna just call it that, that's the maladaptive. The first thing is your relationship with failure, just like you were saying. you have to fail in order to grow. There is no walking without falling. That is a high achieving belief that it's gonna be messy, but we'll get there. Whereas a perfectionist is so stuck on their identity as flawless defines their worth, nobody loves to fail, nobody does. Like, let's just be honest, but there is such a fear of it, such a fear criticism both internally and externally, that they're motivated by everything to just not fail, which keeps them a lot of times in procrastination or not doing the thing in the first place, which we consider in the coaching world to fail ahead of time. So perfectionism, you might think that they do better because of their perfectionist, but because of tendencies like this, they achieve less than high achievers and they stress a lot more. So you really do want to be a high achiever rather than a perfectionist.

The second thing is their relationship with negative emotions. A high achieving well, well adapted person knows the 50/ 50 of life that sometimes there is sadness, there's grief, there's shame, there is all of those sorts of things. A perfectionist will react, resist, buffer. They will not allow negative emotions. They for some reason, feel that they're doing it wrong if they're having negative emotions. But a high achiever knows that part of being human is allowing negative emotions. That's part of the richness of being a human. And if you don't make the negative emotion mean something bad about you personally, you can realize that envy, all envy is, is just letting you know what, what it is that you want. Anger sometimes is a catalyst to move you forward, or you might be aware that you're uncomfortable feeling the underlying emotion. Grief is just an expression of the degree of love that you had. It can be beautiful.

 So third thing is they actually reject success, and this is how. They set their goals so unreachable, so set outside of realistic, that they make success unattainable. And if they do happen to reach this unbelievable marker, they won't give themselves any credit. This is the imposter syndrome where it's just a fluke that I'm here. How can it be a fluke that you're here? Like it's not celebrating any of this success. It's also the arrival fallacy where you just keep moving the goalpost, waiting to be happy, not giving yourself any credit for how far you've come. So this is a real story from an ER doc. Like a few years out from residency, COVID had hit and she was dreading work and like already burning out. She's like, I'm not able to, you know, practice up to my standard and I'm like, well, what does that look like? Like how would you know if you had hit your standard? She had to never miss a diagnosis, but she also had to work incredibly fast, do fast dispositions because it's really frowned upon to hold somebody in the room too long. She also needed to never overwork up somebody, not order too many CAT scans. The consultant had to be happy when she tried to get the patient admitted like, I'm sorry, what? And all of the patients needed to be happy. And when we wrote this down, I'm like, do you see that if somebody even slept wrong, you're not capable of achieving this. This is so outside of your realm of control that no wonder you're having a miserable experience at work. This is never gonna happen, ever. You can't, there are some diagnoses that you're never gonna know unless you overwork up the patient. Right. So you can't have both.

Arpita: Yeah. I mean, the thing is, when you're in your own head, you're never gonna, you don't recognize that. Right? You don't see it.

Amanda: Yes. And the bodies are weird sometimes. They just don't follow the book. Like there's no way of getting it right every time, but also not overworking and all the people happy in the building. Not possible.

Michael: If you are an emergency room physician, hinging your happiness on your consultant's happiness, good luck.

Amanda: And when I rotated in med school and residency off, I would eat my own. I was just, I hadn't slept in forever. Like, that's not their fault. It's unbelievable. So that's the third thing. Okay. So rejection of failure, rejection of negative emotion, rejection of success. And then the last thing is actually a rejection of reality. A perfectionist makes a goal, they expect to go from A to B in a linear fashion, and that is not consistent with living on this earth. It's usually some sort of two steps forward, one step back, all of that. They also are very all or nothing in their thinking. So there is no credit for 95% of a job well done. You might have 20 surgeries and 19 of them go great. But if there's one complication, the whole day is a complete disaster and failure.

Michael: Yeah. And I mean, and how many different ways does this come up for physicians, right? Like you can think about patient satisfaction, right? You can have glowing reviews and all the focus goes onto the one negative comment. And you can just see this in so many different ways that come up throughout physician's journey.

Amanda: Even just putting off projects like you're charting. I don't have time to do my charting. You don't have time to do the whole thing, but you could probably do two, right? It's very weird and, and I see this over and over in my life, very all or nothing, like we're doing it all or we're doing none of it. And that whole, none of it keeps you stuck. That's why a high achiever who knows that like, I can make progress along the way, does more. The other thing with the rejection of reality is, we spend so much time up in our head, if only I wonder if I would've done this, if the outcome would've been different. If only it could have been like this. It should be like this. All of these things are a use of your mental energy that isn't serving a purpose. In this lifetime, in this reality this is how it was gonna happen. How do we know? Because that's how it happened. Done. Move on, let's go. Yes. And then also the whole dread of like what could happen. The only thing that is real is this moment, and that was huge for me with coaching too, is like the rest of it is just imaginary. Right? A different scenario or what's coming up for me. All of that's imaginary. The only thing that is happening in my life right now is the air going in, the air going out. Spend the time with your family. This moment I am safe. Yeah. All of that. Like so much mental energy spent on stuff that may never happen and stuff that won't happen because it didn't happen that way.

Arpita: Very powerful, Amanda, I appreciate you verbalizing it because I think docs don't even take a moment to pause and think about this stuff. You just start to have a little bit more awareness around, oh hey, yeah. You know, look, what am I eating? I'm choosing to create this, and it doesn't have to be that way. And it, it's a huge jump I think to jump from I gotta do it all, its gotta be perfect to, I'm just gonna let it go. And what I will say from my own experiences, letting it go in little bits and recognizing that the repercussions that we imagine are gonna come, don't ever come. Completely freeing, right? That's what really got it to be like, okay, I'm gonna try a little more. I'm gonna try a little more. Nobody freaking notices, right? And you know, even when the sh sh, she hits the fan, whatever we're gonna say, keeping it cool for the kiddos in case they're in the car with you. But even if it hits the fan, we can make it fixed. We can fix it. Right? And that's the part about giving ourselves grace, because we're humans and we all make mistakes. So...

Amanda: Right. Well, and I think our clients think if they stop being a perfectionist, that all of a sudden they're not gonna care. And they're not gonna try and they're gonna be sloppy and they're gonna, that's not even possible for these people. Right? They're so far beyond that. Like, just coming back to here, you're not gonna go all the way to the other end. Like we're just giving permission to be a human being and do the best you can. Especially, yeah...

Arpita: And what if you do go to the other end? Maybe this isn't what I'm to be right? I mean, seriously, maybe it's, this is not what you wanna do and that's okay. This is you figuring out this is not, this is not what you wanna do anymore.

 Amanda: I think ER think if they start giving themself permission, they're gonna be like, I don't care what the workup is, go on and die. You know, like somehow, but that's not, that's not gonna happen.

Arpita: Right, exactly. Exactly. Well, Amanda, it's been amazing. So insightful to talk to you today. If you could give us a take home message, one like bullet that you would wanna offer to the audience regarding perfectionism and how to kind of maybe make some changes, what would that be?

Amanda: Well, the biggest thing would just be you are a human being on this earth, that is real. That is how it went down in this movie version. Right? And you are allowed to be a human. You have permission and there's really no other possible scenario here. I wish, if it were possible to be perfect, I would advocate all about it. However, it's probably leading to a lot of the, at least burnout for me and I just feel so strongly that like our people are the ones that showed up when the whole world wasn't gonna pick around? And they showed up anyway. And we didn't know if we were gonna get our kids sick. We didn't know what was gonna happen. So why would we be punishing ourselves? Like I feel like we deserve to be happy and we shouldn't be hurting ourselves on some unrealistic standard and not like just working on that voice in your head to be more compassionate. You're just trying your best. You really are, and that's really all that the world needs from you. I promise.

Michael: And adding on to your message, because I know you, the importance of community because the compassion comes so much more easily when you surround yourself with a community, with an understanding community that can empathize and sympathize and that knows you and cares about you. And I know that that's been a central theme for you in your work and the thing that you
try to promote. That's part of the reason why you have The Whole Physician. Right? And, and we didn't talk about this, but the whole physician, your partners in that, are people that you've known and trained with for a very long time. These aren't people that you just met in your current job. These are people that have been part of your community for such a long time. And I know that that is super important for you. So speaking of The Whole Physician, tell our listeners and watchers where they can find you and your partners.

Amanda: So the website would be www.thewholephysician.com. We also have a podcast called the Drive Time Debrief with the whole physician. The idea is if you're coming out of a crazy ER shift or whatever shift and you're like, you know, whatever, you can just put it on and hopefully get home in better condition than when you got in the car. I kind of needed that for, for my, my journey. That would've been helpful. And then we do have a CME course that we've released. So if you have CME funding from wherever you work, you can use that to take our course. It's called Wellness 911, and you can get information from that on our website.

Arpita: Awesome. Well, thank you Amanda. We really have enjoyed having. You such a heartfelt conversation that I think a lot of people need to hear. So thank you again for joining us today and thank you for being a one of our people in our tribe.

11. When Being Perfect Isn't So Perfect - with Dr. Amanda Dinsmore

Amanda: Thank you. Thank you for having me. It was an honor.

Arpita: Awesome.

Michael: Absolutely. Take care. Bye guys.