‘I gave you the chart. The chart had the orders on it. This is not my problem. It’s yours.’
With that, I stormed through the department into the physician office. Angry tears pricked at the corners of my eyes, and I threw down the chart in my hand, growling my annoyance. Several heads swivelled, several pairs of eyes focussed on me. I was making a scene in front of two attendings, a nurse, and two off-service junior residents, and I didn’t care. I was making myself look awful, just a terrible hothead who wasn’t able to control her emotions. My cheeks burned. My throat tightened. I couldn’t believe that nurse had lost the chart, failed to report it for two hours, and then blamed it on me. I was incensed. My anger was legitimate, but I was expressing it in a way that clearly was not.
I mentioned in a previous post that I suffer from a terrible temper.
I use the word ‘suffer’ because there’s actually a lot of suffering in having a bad temper. Nobody likes to feel like their emotions are out of their control, and I know that I cause destruction and personal and professional difficulty when I let anger get the best of me. When I’ve been unkind because of a loss of temper, berating myself seems the natural course, so I pile suffering on top of suffering.
Naturally, those around me suffer my bad temper, too. Nobody likes to be in a close personal or professional relationship with someone who is a loose cannon. It’s not nice to bear the brunt of unkindness or the unpredictability of someone who loses their temper.
I’ve put in a lot of work over the past while, particularly the past several months, to tame my temper. It’s not easy. I promised in my previous post to talk a bit about strategies I use to control my temper when I feel an outburst is imminent. It’s not evidence-based, but maybe it’ll help some of the loose cannons out there.
Make a kind attribution.
For some of us, it’s natural to make hostile attributions. In other words, when someone does something we don’t like, we assume that they have done it for all the wrong reasons. This can be self-protective, as when we avoid trusting the untrustworthy, but in most situations it isn’t all that adaptive.
In my professional life, it’s a short cognitive and emotional leap from a nurse questioning one of my orders to me assuming he thinks I’m incompetent or is trying to undermine me and make me look bad in front of my supervisor. In my personal life, I might assume that when a friend cancels plans it’s because she prefers spending time with someone else or simply doesn’t like me, or I might decide that my partner is purposely ignoring me when I don’t receive an instant text back. It’s not that I go out of my way to make these guesses about the behaviour of those around me; it’s just the place my brain goes.
If our brains can go to one place, then they can definitely go to another. I am a big fan of trying to make the kindest, most charitable attributions about people that I can. It doesn’t come naturally, but that doesn’t mean that it can’t – or shouldn’t – be done. When I feel undermined, ignored, or rejected at work or in my personal life, I try to flip the script and imagine the kindest reason someone might have done or said what they did.
That nurse who questioned my orders? Well, maybe my penmanship was bad or I made a critical error and she is helping me avoid hurting a patient. Perhaps he’s just interested in hearing the logic behind a technique that is new or different from what he’s seen before. Maybe she’s just curious. Sure, it’s possible that that nurse has it out for me, but it’s way more likely that the explanation is a benign one.
Similarly, maybe my friend hates me, but maybe she’s just really tired after a long day at work. It’s possible that she overbooked herself, heard bad news from her parents, or hasn’t had a good night’s sleep in days. That ignored text? Maybe he just fell asleep on the couch. Not like I haven’t done that a hundred times myself. Perhaps the text arrived during a bad moment and he completely forgot to reply to it.
The funny thing about making a charitable attribution is that it’s most often more accurate than a hostile attribution would have been. And it always takes the angry wind out of my sails.
Replace negative cognitions with positive ones.
Along the same lines as making a kind attribution is replacing negative cognitions with positive ones. The entire basis of cognitive behavioural therapy is recognising maladaptive cognitive patterns, interrupting them, and replacing them with better thought patterns and coping strategies. I’m no therapist, and I don’t have any training in CBT, but I have found that a mindful approach to my own cognitions allows me to recognise and interrupt the patterns that result in angry losses of temper.
I’ve come to recognise that a lot of the cognitions that precede my own anger are couched in fears about inferiority, insecurity, and uncertainty. Not an earth-shattering revelation, is it?
I hate to admit it here, but since this blog is all about authenticity and vulnerability (and here you just thought it was about my musings on residency!), I’ll say it: I worry about not being as ‘good’ as my peers. I study. I’m smart. My interactions with patients and their families are generally excellent. My performance on exams is generally good. Still, I worry that I’m not measuring up. I think it’s a fear that a lot of us face during our medical training, even if we don’t often talk about it out loud. It’s hard to know where we fit in relation to our peers. Compounding that, different sets of skills develop at different rates for different learners, so that one resident might have outstanding interpersonal skills but may not yet have excellent technical skills, and another might be blowing it out of the water on exams but still struggling with how to turn theory into practice. We all tend to speak up when we have a chance to shine, so we often don’t have a good sense of where our fellow learners are struggling. The result is that we see everyone shining where we are struggling, and we never seen anyone struggling where we are shining.
When I’m feeling insecure or inferior, I try to remind myself that I don’t know where my peers are at, and I try to trust the system to let me know if I’m falling behind. Sometimes it’s enough to remind myself that I’m an intelligent and thoughtful learner, or to reflect on my successes, even the really small stuff like a smooth intubation, well-executed lumbar puncture, or compassionate delivery of bad news.
When I’m not operating from a place of self-defence where I am constantly trying to prove to myself and others that I am exactly as good as everyone else, I am far less reactive emotionally and way less likely to act in anger.
Remember that ‘right’ is both subjective and unimportant.
I love being right. I don’t know anyone who doesn’t. Still, sometimes being right isn’t important. Sometimes what’s most important is making sure the right things are done for a patient, or a friend is given the right supports, and it doesn’t matter whether I get to claim credit for that or someone else does.
As importantly, there’s not always one right. Sometimes I get so hung up on being right that it’s hard to let anyone else have an opinion different from mine, medical or not. It’s not easy, but I am trying very hard to recognise that there is immense variation in the way people live their lives and the way physicians practice medicine. It’s hard to allow for these variations when I think I know the one ‘right’ way, but I am increasingly learning that literally nobody gives a shit how right I am, how many papers I can quote, or how certain I am that the nurse lost the chart and not me. People care whether I am kind, a team player, and respectful of the opinions and beliefs of others. They care that I practice medicine safely and humanely and play well with others in the sandbox.
There’s nothing as unbecoming as being disrespectful, not even being wrong. So while I strive to be accurate, safe, and ‘right’, I am learning to choose my battles and recognise those times when I don’t need to push for my one ‘right’ way.
Create physical distance.
The simplest strategy, and perhaps the most useful heated moments, is often the hardest to execute in the rush of the emergency department. Still, I find that when I’m really about to blow, physical distance is key. Sometimes we just need to walk away. Even the harshest of attendings will usually not mind if you take a bathroom break, and I’ve learned that the bathroom is one of the best places to silently scream and roll my eyes. If you can swing it, a brisk walk around the hospital – or better yet, outside – is invaluable. Sometimes just asking someone else to take over interactions with a particular individual, even temporarily, can give you a bit of breathing space.
Nothing is more aggravating than standing in the same small space with someone who is getting under your skin; get out if you can, even just for a little while. Let the engines cool.
Fake it until you make it.
At the base of it, I’m still a person with a terrible temper. But I’m learning that sometimes you’ve just got to kill ‘em with kindness. So when I’m really annoyed, I try to paste on a smile, adopt a pleasant tone of voice, and just act like I am the person I’m striving to be. Funny thing is that I’m usually less irritated with a smile on my face – even a fake smile – than I am with a scowl.
I haven’t yet mastered even one of the above techniques. I’m working on it, and I’m getting there, bit by bit. Progress is slow and difficult, and setbacks are common, but I believe I am moving in the direction of being a kinder and gentler person, and a better teacher by example in my daily life. My hope is that my story might be some consolation, and the above tips might provide a place to start, for some of my fellow hotheads.
May you do no harm and take no shit.