Some thoughts on C/L, performance vs. growth, and “pager anxiety”

At the start of October I switched from my three-month Consultation/Liaison (C/L) rotation to the Adult Inpatient Program rotation, which will run through the end of December.  I found the C/L rotation challenging in multiple ways.  There was so much interesting psychiatry that I got to see and learn, with many clinical situations I hadn’t encountered previously, and I admit that there was a certain level of excitement that came with the pace of the service.  At the same time, I had to come to terms with the fact that I really don’t like to work at the behest of a typically-busy and always-unpredictable pager, and I very much don’t like to feel rushed.  

As an example of unpredictable and rushed: one afternoon the service pager stopped working without us realizing it.  Fortunately there was a workaround that involved forwarding the pager number to a personal pager.  But after the service pager got reactivated the next day I simultaneously fielded pages—including a couple of “We tried to consult yesterday but never heard back” calls—while exchanging emails with IT to figure out why the pager had stopped working in the first place.  Put another way: I found this work quite stressful.  There were more than a handful of nights where I woke from a vivid dream that I hadn’t finished a note or clearly signed out a to-do, and would have to convince myself that it had simply been my anxious subconscious and not an actual daytime lapse.  

It’s not that I didn’t have enough support or encouragement during this rotation; in fact, I was grateful to receive feedback that I was adapting to and handling the work well enough, and I discussed my qualms with both faculty and older residents.  But on a deeper level, my anxiety in trying to adapt to this workflow still made me question my own competence.  I intellectually understood that it was ok if this particular style of work wasn’t “my thing,” and that it was ok if I didn’t feel a sense of equanimity (to say nothing of mastery) when holding the consult pager.  Realistically, how could a resident at the start of their PGY-2 year be expected to have or feel mastery over anything in their specialty?  But I was afraid—and when on a call shift, especially, I am still afraid—that if I were to become overwhelmed, I would make a mistake that would affect patient care, or would not get everything done during my shift and would need to sign too much out to the next resident, or would need to stay far too late to finish my work.  What this all adds up to, in my head, is that I might be insufficiently efficient or effective, that I might be the weak link on my team.  I think that at the root of my “pager anxiety,” a fear of being overwhelmed connects with a fear of failure.

At some point in the past I read that residents go through several stages of growth which I loosely recall as 1) not knowing how much they don’t know; 2) knowing more than they did at the start but also realizing how much more there is to know, and so feeling discouraged and less confident than they should feel; 3) thinking they know more than they actually do; and thus feeling overconfident in their knowledge/abilities; and 4) realizing that they know a certain significant amount, but balancing that with the need for ongoing learning, and therefore calibrating confidence more appropriately.  Recently I joked to my therapist that stage 3 sounded nice because I was definitely still in stage 2, and very much worried about how much I have yet to learn.  Six months of psychiatry during intern year and three months on the C/L service felt like a mere scratch on the surface of this enormous field.  

In thinking about my “pager anxiety,” I’ve been thinking about the difference between a “performance mindset” and a “growth mindset,” which was a contrast drawn for us at the start of residency by one of our program directors.  As medical students, it’s impossible to avoid the performance mindset, as we are in fact constantly being evaluated and our future trajectory (i.e. residency prospects) depend in large part on those evaluations.  As new residents, we were encouraged to shift into a “growth mindset,” since we now have the opportunity to focus on patient care and our professional and personal development as clinicians / scholars / scientists / public servants / teachers / etc, without the same pressure of performance evaluations every couple of weeks.  

At this stage of residency, I can certainly look back on the start of intern year and recognize the considerable growth that has occurred, and anticipate much more to come.  I know I am still susceptible to the performance mindset, and on some level I don’t know that I will ever be able to entirely set it aside.  It does matter to me to feel like I am delivering “good” or even “excellent” clinical care, and also that I am meeting or exceeding expectations for my role as a trainee.

But what does it mean to be “excellent” in this work?  Hospital quality metrics aside, I’m starting to realize that on a personal level there is a risk to chasing the feeling of “excellence” if it is tied to a sense of surety, mastery, or ideal patient outcomes, when the very nature of residency training is that we are learning how to do this job, and especially when the nature of psychiatry is that our patients’ presentations and trajectories are multifactorial and often unpredictable.  On top of that, even without the COVID-19 pandemic, the system simply doesn’t allow me (or anyone else) to deliver perfect care.  There are too many patients and not enough providers, and so I simply can’t spend as much time talking with each of my patients, poring over their histories, or pondering their formulations as I would like.  To do so, I would need to routinely work until 10pm or later every night (not even taking into account those call shifts!).  

As such, I have to balance my own high expectations with what is realistic and sustainable.  I have to continue to ask for help when I need it, and to believe that I will continue to become more knowledgeable, efficient, and effective as my training progresses.  I need to keep working to build my internal locus of control and confidence, while keeping faith that my threshold for feeling overwhelmed will continue to rise.

And, if all else fails, the beauty of shift work is that each shift eventually comes to an end, and then comes a time to rest, reflect, and prepare for the next.

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