DTD 158
===
[00:00:00] This is the Drive time debrief, episode 158.
He Hey guys, welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today we are diving into a thought error that many docs struggle with. We see it over and over and over, and it's called the internal control fallacy. This is one of the 15 or so major cognitive distortions within [00:01:00] cognitive behavioral therapy.
It's the mistaken belief that we're responsible for controlling outcomes beyond our influence. Like for instance, how our patients react or whether our team feels a certain way. It's the belief that we're responsible for or even can control in the first place other people's feelings, actions, or outcomes.
In this episode, we'll discuss how this fallacy plays out in medicine, why it's so harmful, and what we can do to break free from it. So let's get started. Okay, so what exactly is internal control fallacy? Well, in cognitive behavioral terms, it's a tendency to overestimate our ability to control external events or other people's emotions and behaviors.
So it's very others focused, like outside of us. Like, not in our control. Others business, right? It's the belief that we have more control over external events or people than we actually do. We mistakenly think that if we just try a little harder, we can fix everything. If we would [00:02:00] have done more, this would have been different, even if it was never really in our power to do so.
For example, outside of medicine, someone might believe, if my partner isn't happy all the time, I'm failing them. Or if my child has A diagnosis fails out of college, gets bad grades, whatever, it's because I didn't do something right. In the context of medicine, it might show up as thinking, if my patient got worse, it must be because I didn't do enough.
Physicians often believe they're responsible for whether a patient follows their advice. Whether a family accepts a diagnosis well, or whether their team is always happy at work. Many believe if the waiting room is full, it's because they weren't fast enough. Or because they just keep coming in. Because the light is always on.
Open! If a consultant doesn't like their admission, it's because they didn't do a thorough enough workup. Sounds like an issue, not an ish me. Internal control fallacy falls into what many psychologists refer to as stepping into someone else's business. And we did do a [00:03:00] podcast on whose business is whose renowned mindfulness teacher, Byron Katie often discusses how taking on responsibility for someone else's feelings or outcome is both unrealistic and unsustainable.
If you believe you can or should control someone else's choices and consequently the results of their choices, you're stepping out of your lane. And here's the key. There's a big difference between influence and control. The reality is we can advise, educate, support our patients, but we cannot and should not assume full responsibility for their choices.
We can't make them change. That's their business. I think this is huge in relationships, especially like, the thing I was talking about outside of medicine, like our partners. I mean, that's huge. Like they aren't responsible for our happiness and we aren't responsible for them. And sometimes we get bitter and resentful at them because we're not happy.
But really, if we just took that back and started doing things, more things that bring us joy, that might, I don't know, be something to [00:04:00] think about. I think it's so interesting. This comes naturally to most of us, a lot of us grew up in situations where we were told, don't hurt their feelings or did they hurt your feelings or maybe like where I grew up.
I felt like I had to stabilize the environment and had to, like, do everything I could to keep certain members of my family calm. And while that's a great, adaptive strategy when you're a kid, it sets you up for a lot of unhealthy patterns as an adult and really, really wear you out. So, yeah. Well, and here's the thing.
A lot of us have Patient satisfaction scores that are reported. And sometimes, I'm telling you, there is nothing that you could have done. We had one really good practice manager that was like, they get their bill, and they're mad about their bill, and then they fill this thing out. So she [00:05:00] wouldn't even show us half of it.
She wouldn't show it most of the time, because most of them, Were that if there was something constructive, then she would, but it's like, you think that it's a reflection on you and it just might not be and is it fair that you're even graded on patient satisfaction anyway, probably not again, outside of your control, unless you're in admin or something.
So this applies to so many things in our lives, at home, at work, everywhere. And it's crazy how quickly we will go to trying to control and it's not always like controlling in the way we think, but even just trying to make someone feel better about a situation that they're struggling with.
Can be us trying to control the situation. First of all I didn't even know that this was just a thought error like a well described thought error that lots of people have I Again, this was back before I knew that you could challenge [00:06:00] your own thoughts.
I just thought this is Reality, this is how it is and I just need to try harder, you know, so a big point of this podcast is since we know so many of you out there struggle with this is to give you words. To describe what's happening and then let you detach from it. Yes. Yes. And so just to be clear, because honestly, this was really confusing to me at first.
It was so much a part of who I was. You are in charge of your feelings. You're in charge of your own actions and thoughts and what you do with your life. You can offer influence. to those around you, but it's inappropriate to try to control them and say, you know, you, you have to do this, or I'm going to be unhappy.
No, that's, that's an immature stance. More appropriately would be, you know, when this happens, I don't feel great. And my request is that you don't do this anymore and recognize that they [00:07:00] can do what they choose with it. And then you can choose what to do with that. But let's talk about how this fallacy impacts physicians negatively.
There's just three major negative consequences. Which include increased guilt, burnout, and emotional exhaustion. So firstly, guilt and self blame. So imagine a scenario where you're treating a patient with uncontrolled diabetes. And I imagine those of you in primary care, like, this has got to be, this has got to be so incredibly frustrating.
Because I know that you probably have several of these patients. Despite your best efforts and clear guidance, Their blood sugar remains poorly managed. So if you're caught in the internal control fallacy, you might think like, I'm just not an effective doctor, or I must have done something wrong, and I'm failing my patient.
But we know that that patient's autonomy, their own agency, means that while we can give them expert advice, their decision about what to [00:08:00] eat, Whether to exercise or not, lies with them. So their blood sugar is their responsibility. Their choices, lifestyle, and other circumstances, you know, like certainly if they're living in a really stressful relationship or something else is going on that makes it hard to do the things they need to do to control their blood sugar, That is not your fault.
That's not your fault. And if they can't, if they can't afford their meds, that also isn't your fault. No, no. That is not yours to solve. That is not your problem to solve. And the reason, you know, certainly if we could fix everything fantastic in the world, we can't, we absolutely can't, but what we can do is wear ourselves completely out trying and then they don't have a doctor or they have a doctor who is a shell of themselves.
So it's just not, it's not useful. So, when we have this misplaced guilt. over something that is not ours. We'll increase feelings of inadequacy. You know, [00:09:00] definitely imposter syndrome can sneak back in there. And research by Tate Schoenfeld from 2019 highlighted that unrealistic feelings of responsibility.
This is also called overfunctioning. for patient outcomes can significantly contribute to physician burnout and moral injury. So if you're feeling burned out, this is a great opportunity to just look and see where you're taking on responsibility that is not yours. and see what you can do to address this thought error.
Number two, burnout and overfunctioning. So consider how overestimating our control leads to overfunctioning. We'll take extra call, we'll see more patients. One thing we see a lot is working for no pay. We see that in multiple different specialties, those of you who are in primary care and you are seeing patients and then spending hours and hours at night and on the weekend, charting and answering inbox messages.
This is [00:10:00] you. When we're seeing more patients than we can recently handle, we're doing all these countless hours on tasks, believing that if we just do a little bit more, we can fix everything that relentless effort to control. The uncontrollable is a major contributor to burnout, which as we know, it's more than 60% of us who are experiencing burnout now.
Those are just the ones admitting it slightly more. It's like trying to push a giant boulder up a hill. Only to have it roll back down on its own or over you. In some cases, we just like for real, we just end up feeling exhausted from trying to meet. These unattainable standards. Yeah, I, I see this like, yeah, I see this like an, an EM like partners that are just like constantly covering for other partners.
I mean, stuff comes up. We all need like shifts covered here and there, but I think they're, you know, if you're doing it at your own, like, physical exhaustion or, you know, mental and whatever exhaustion probably [00:11:00] want to check where that overfunctioning is coming from. Cause it's definitely to some burnout.
Yeah. You know, Brene Brown talks about this, Harriet Lerner's book, you know, anxiety can, anxiety and fear and like uncertainty can manifest. Either as over functioning or under functioning. So we have clients too that pick up extra shifts, extra call, extra this, do all these hours of things, those over functions, but can also manifest as under functions where they like shut the door, shut the blinds, and shut the whole world up.
Just shut down. So this can manifest in both ways, but both of them are going to eventually lead to burnout if you're not already feeling it. Right now. Yeah. Yeah. I, I also see it a lot. We have a lot of clients in underserved communities and people drawn to those places have a giant hearts to begin with.
And I see them like over, overworking, overdoing, overachieving because the thought is if I don't, who will? And you're right. There [00:12:00] isn't just a giant pipeline coming in, but again, they're not going to have anyone if you don't make this sustainable. Yeah, and we've talked about this before, but when we overfunction, it causes the rest of the system to underfunction.
So when we're overfunctioning, we're actually making the system more broken. And I know some of you are like, what? No. Yes. Yes. That is what is happening. The more we overfunction. It's just a new level that they're expecting us to achieve. You know, there was probably some time in the past where doctors had an hour with their patient.
No more. No more. Yeah. Because somebody was over functioning and they were like, Oh, well you're doing it at that level. Everyone needs to do it at that level. And we try to preach to you guys, medicine will never say, Hey, you've reached your limit. Don't do anymore. It will never say that. No. As long as no one upstream is feeling the heat.
As long as no one else can tell that it's broken, it sometimes is going to [00:13:00] have to, the wheels are going to have to fall off sometimes for them to get upgraded wheels. You know? Yeah. Yeah. If you compare. Keeping it together for everyone. Yeah. And here's your clue if you're doing this. If you are feeling resentment, that is your best self telling you that there is something you need to address.
That it is you. It is not the situation you're in. You have a boundary that you need to enforce. You need to identify what the boundary is and you need to enforce it. That's good. Yeah, I mean, it's, it's your signal. Listen, I'm on my soapbox about it because it's annoying. It's, it's annoying because the system will take advantage of people.
Why wouldn't it? Yeah, why? I mean, it makes sense. It makes sense. It's great. Yeah. Until it is fully broken, but yeah, up until the whole thing breaks. And we can all see it, we can all see it teetering close to the cliff. It's not working anymore. [00:14:00] No! Alright, number three, emotional exhaustion from patient and family reactions.
Okay, so What we do is I don't, you know, I don't know what it's like to be a computer programmer or like a cyber security expert. I do know that the emotional toll of what we do is high where, you know, some of us. Are introverts and peopling is exhausting. I had a client talk about spoon theory. And if you're not familiar with that, it's like you have a certain amount of energy at the beginning of the day and it gets used up.
And if it gets used up before the end of the day. Then you're just wiped. And this happens, especially when you're experiencing interactions with people where you are so invested in how they feel that you wear yourself out. So a lot of us think that we are responsible for how patients and their families feel.
I, one thing [00:15:00] that like one, I would struggle with a lot and is. Is still, I still try to contain myself and contain, like have a containment boundary around is people bringing in kids who are completely unvaccinated. And it's more and more of them all the time. It used to be if, if I could just explain to them, and tell them about the kids I've seen who've died from preventable illness, if I could just like, let them pictures of kids who are.
You know, gorked out from meningitis from Hib or from pneumococcus. They would do it. No, no, that is not my job. They say they do their research. It is their responsibility. I can try to offer some influence, but I've got to let go of that. And it's hard when it's a kid. You want, you know, you want that kid to live and be healthy.
It's not my responsibility who they got for parents. So, like. Have you ever given a perfectly reasonable medical [00:16:00] recommendation and then the patient gets upset? Yes, I'm sure any of us who practice through COVID know that. Would you like a COVID test? And then they go ballistic like I've had that a few times and then you feel like you did something wrong Like did I like?
Did I say that in a rude way? It's just a microchip, people. Chill out. I mean it. Right. So if you're harboring the belief that you're responsible for their reactions, this is going to lead to a lot of emotional strain. We have to remember that the things we say are oftentimes not what they hear because they're hearing through their own lens of Their own experience.
And so we can say something in the kindest way possible and they can still receive it wrong. So a study published in the journal of general internal medicine in 2018 found that physicians who assume excessive emotional responsibility for their patients experience higher levels of distress and depersonalization.
When we get wrapped up in these. like drama [00:17:00] situations, we will actually over time lose empathy and in a lot of ways lose who we are as a doctor. So it, it seems counterintuitive to just separate ourselves from their outcome, just focus on how we're showing up, making sure we're showing up the way we want to.
It seems like that's more uncaring as actually not. It's actually a much more sustainable way to care about people. And many doctors think, If I just say it the right way, they won't be upset. Nope. It's impossible. Like I said, everybody has a filter. There's no objective reality between people when they're interacting.
Each person has a filter based on their own beliefs, their own past experiences, and As whatever you say comes through that filter, like as I, as I asked my patient, if he wanted a COVID test, it came through the filter of this doctor wants, you know, whatever it was, they thought that I wanted to do when, in fact, that [00:18:00] wasn't making money from big pharma or something, but it was, you know, it's not true from my standpoint.
It's true to them and that, so I can't control that. You can't control that. You just can't control it. And remembering that their reactions are their business and our responsibility is to take any helpful information. Like if they yell at you and tell you yours, your fly's unzipped or something. Okay.
That's helpful. I'll zip my fly up, but anything that's not helpful. We need to learn how to keep a protective boundary and. Keep it out, because that kind of stuff will just suck your soul out. Like, literally, suck your soul dry until you're just like this hollow version of yourself.
It helped me to realize with some of those, some, sometimes when people have reactions that I'm not expecting, is that if everyone that they love the most in their lives is telling them the same story over and over, [00:19:00] that's different from your story, we've talked about this also before in a podcast, cognitive dissonance, the brain does not like that, and probably they're going to go with what their loved ones said over you, they don't even know you, Right, so that helped me let that go.
It helps me also still care for them. Yes. Also still give them autonomy and exert as much influence as I can because here's the thing if I'm getting worked up, I'm not gonna There's another one that I'm not gonna be able to influence at all. Yeah. And so I've got to check myself, stay in my own emotional maturity, stay out of my own judgment.
To be my best self. That's all I can control and I'm going to do my best, but I'm also going to let go of I just have to let go of a lot of things that I don't have control over. Yeah, and if you're wanting to influence them, staying calm there, you know, our brains have mirror neurons that tend to copy what we see someone else doing.
They are much more likely [00:20:00] to chill out and be calm and be able to receive whatever information you're going to want to share with them. If you yourself are being calm, if you have amped up, then they. They are not going to be in any place to be able to receive anything that you have to tell them. I mean, yeah, not to, not to dwell on it too long, but propaganda taps into emotions.
And your logical, I think we've also, we've said a lot of really good stuff on the podcast, but if they're in their emotional brain, you're not going to reach them with your logical facts. So just keep that in mind. And the propaganda that they're getting is terrifying. So. So there's that. So, strategies for breaking free.
Let's talk about some ways that we can start to loosen up the grip that internal control fallacy has over us. Number one, just recognize it. And that's a lot of what this podcast is, is I just didn't even have the words, or the understanding of what was happening to me. The first step always is [00:21:00] awareness.
So next time you notice yourself thinking I should have done more or it's my fault that they're upset pause. Oh wait Maybe this is internal control fallacy remind yourself that these feelings are rooted in an unrealistic belief of control Number two and that might be all that you are able to do at first is just awareness and you still Do the same behaviors over and over But it's making a little crack in that wall.
Number two. Separate influence from control. Ask yourself, What aspects of this situation are within my control? Usually, it's only my actions. My, the advice I give, the way that I give it, my empathy, my professionalism, my own emotional stability in this situation. Anything else, like a patient's personal choices, what they perceive of me, that comes from, that comes from their own history.
A family member's reaction, all of that is beyond my control. Then number three, reframe your thoughts. If you catch yourself thinking, I [00:22:00] failed because this, I failed because my patient didn't improve, try reframing it to something that is more within your control. I provided the best care possible, and the outcome is now in my patient's hands, or even in God's hands.
This small shift can alleviate a lot of unnecessary self blame. Number four, set emotional boundaries. Before challenging patient interactions, remind yourself that the emotional reactions of others are ultimately their own responsibility. Sometimes I get out of the bed and I'm just cranky. There's nothing anybody did.
I just feel grumpy that day. So you cannot take somebody else's emotions personally either. If I can barely even control my own emotions, how am I going to control somebody else's? Their emotions, their reactions, say ultimately more about them, their situation their backstory, than anything about you.
And this mental note helps you create a healthy emotional distance to stay grounded and show up in the best way that you [00:23:00] can. And then number five, again, we're reiterating to stay in your own business. It just ties back to our core message, stay in your business. As physicians, our business is to provide good care, not controlling other people's outcomes or emotions.
Yeah, I like that. We just keep about our business, keep it straight people, and realize that there's a whole bunch of this that comes at us that is totally out of our control. This internal control fallacy really can lead us down a path of guilt, burnout, and emotional exhaustion. Just like you said, you have a set amount of energy every day.
When you wake up, feet hit the floor, you are given The time is the same and energy and you get to choose how both are spent. So choose wisely by recognizing this fallacy, reframing our thoughts and setting healthy boundaries. We can reduce stress and refocus on what truly matters. Caring for our patients without overextending ourselves.
Hey, can I add one more thing that I just thought of that I think we've [00:24:00] referenced it before on probably Boundaries podcast, but Brene Brown says that she, you know, in her research she found that the people who were the most compassionate were the absolutely most boundaried. That if we can, so this is not like, we're not saying to be selfish.
We're saying this is how you can be your best self. We can all be our best selves is by maintaining those boundaries. So we can maintain compassion and not. Be filled with resentment.
Yeah, that's really good. So, have you experienced internal control fallacy in your practice, Laura? Oh, yeah. How did you cope with these challenges? Well, if you're listening today, and this struck a chord, or you remembered something that happened, reach out to us on social media, send us your feedback. You can always email us.
Podcast at thewholephysician. com and let's continue this conversation. We are here to support each [00:25:00] other and we love to support you in this. So if you found this episode valuable, please subscribe to the drive time debrief with The Whole Physician and share it with your colleagues. Just so you know, you're never alone.
In the show notes, there's a link to talk with one of us. There's also a link for our free video, How to Crush Physician Burnout for Good Without Cutting Back Hours, Quitting Medicine or Sucking It Up in Silence. Thank you for joining us today and until next time, you are whole, you are a gift to medicine, and the work you do matters. [00:26:00]
