The Inner Bully and the Burden of Charting: A Dose of Self-Compassion May Be the Best Medicine

October 01, 2020

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

If you are a physician, this may sound familiar:

I can feel that old resentment bubbling up as I sit down to chart on a beautiful summer Saturday afternoon. Seventy-two hours and I have to get all the charts done or they will close themselves automatically, and my name is added to the departmental “late charts” email list. My daughter is waiting for me to take her to her mall. It’s always hanging over me, and I can’t stand the stress. The minute I login, I hear the familiar self-critical voice and internal task master who whips me to get the job done:

You’ve never been very good at this, anyway.

Everyone else is so much faster than you.

Why can’t you just get your charts done like everyone else?

Just sit down and make yourself get it done!

And further, throughout the COVID-19 pandemic, you may be charting from your living room, dining room, or bedroom. From the lack of interaction with colleagues to seeing patients via videoconferencing or through layers of personal protective equipment (PPE), medical practice is isolating. Whatever semblance of work-life balance you eked out prior, it has now definitely gone out the window.

This is the story of many frontline providers during the pandemic. Working from home, charting from private spaces at all hours of the day, and experiencing the harsh inner voices telling them that they’re inadequate in one way or another.

It is indeed a difficult time to be practicing medicine. The demands are many, and much is out of our control. But, what about those pesky negative inner messages?

It turns out that many physicians have a lot of these critical inner messages. We can be our harshest manager, saying things to ourselves that we’d never say to another colleague. For one physician, it’s the voice of an attending from her intern year, telling her she’s just not shaping up. For another, it’s in the form of a harpy who’s always looking over her shoulder, wagging a finger of blame and shame. It’s sometimes so prevalent that we don’t even notice the background noise, and at other times, it’s like there’s an inner bully constantly judging us and coming down hard on anything we don’t do just right.

This inner chitchat can really wear us down. But many of us believe we need to be harsh with ourselves or we won’t achieve anything… that we have to berate and push ourselves. But does this negative messaging truly help us get through the load of charts and other administrative tasks more effectively, or does it just drag us further down?

Are you more motivated by criticism or kindness?

Let’s try a brief exercise to find out. Visualize yourself sitting down to chart. Imagine your computer screen, and where you would be working. Start by telling yourself that:

You don’t have what it takes to get them done. You are nowhere near as efficient at charting as your peers. You are not as smart as others. You’ll be lucky if you ever get on top of the charts.

Now rate your level of motivation on a scale of 0-10, where 0 equals no motivation, and 10 equals “Let me at it!” Write down your number.

Now, visualize the same charting. Tell yourself that:

You are great at charting. Your level of efficiency is just fine. You are an outstanding physician. You have exactly what you need to excel in charting and in your overall career.

Now re-rate your level of motivation on the same 10-point scale. Did your number go up, down, or stay the same? Most people see an increase in their level of motivation. In other words, those negative inner messages do the opposite of motivating you to improve.

Importance of self-compassion

Another approach is to treat ourselves kindly, just as we would a close friend. Research shows that people who practice self-compassion cope better with difficult situations, experience less fear of failure, and have greater overall life satisfaction. Self-compassion also benefits our physical health, including decreased severity of chronic pain, decreased alcohol consumption, and increased regular exercise. In addition to these benefits, self-compassion improves our ability to practice productively, increases joy in caring for our patients, and builds resilience to the pressures of our careers.

After all, you likely have compassion for your patients. If you don’t have it for yourself, there can be a sense of separation from those around you, as if others are worthy of compassion and we are not. Over time, this depletes our inner well of resilience and contributes to burnout and exhaustion.

With self-compassion, we see that suffering is occurring. Ours. We remind ourselves that suffering is part of everyone’s existence. Other colleagues are suffering as well. We greet our own suffering with kindness.

And while we might consider self-compassion too soft, weak, or selfish, none of that is actually the case. In fact, it may very well be the opposite.

Take a self-compassion break

You can build compassion for yourself with what is known as a self-compassion break. Employ it whenever you’re having a difficult time, come up short on a task, or notice something you don’t like about yourself.

  1. Call to mind whatever difficulty you’re currently facing… see if you can actually feel the stress and emotional discomfort in your body.
  2. Put your hands over your heart or another part of your body that feels right, feeling the warmth of your hands and their gentle pressure on your body. Say these words to yourself:

This is a moment of suffering. This is hard. This is how it feels when someone is going through what I’m going through. Suffering is part of life for everyone.

  1. Now say the following to yourself:

May I be kind to myself in this moment. May I give myself the compassion I need and deserve. May I support myself in whatever ways will help me. May I learn to accept myself as I am. May I care for myself just as I would a loved one or dear colleague in need.

If you find it difficult to direct compassion towards yourself in this way, imagine that a good friend or loved one is going through what you’re going through. What would you say to them?

  1. Take a moment to reflect on how this exercise made you feel. If it felt uncomfortable, that’s likely because you’re used to being less than kind to yourself. As you go through your days this week, keep taking regular self-compassion breaks. The more you use this exercise, the easier self-compassion will come to you.

This practice can feel very foreign, almost contrived and artificial. Yet, it is a muscle that we can build, bringing ourselves the same care we so readily bring to our patients. Perhaps you can try it out for yourself and see.

Feature photo by Aleksandr Ledogorov on Unsplash


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Gail Gazelle

Gail Gazelle, MD, MCC, is a part-time Assistant Professor of Medicine at Harvard Medical School, Master Certified Coach (MCC) for physicians and physician leaders, and certified mindfulness meditation teacher. She is the author of the 2020 book, Everyday Resilience: A Practical Guide to Build Inner Strength and Weather Life's Challenges.


Paula GardinerPaula Gardiner, MD, MPH, is an Associate Professor at University of Massachusetts Medical School in the Department of Family Medicine, as well as Associate Director of Research and Director of the Group Visits Program in the Center for Integrated Primary Care. She is a Certified Instructor of the Mindfulness Practice Curriculum developed by Krasner & Epstein, completed a 2-year Mindfulness Meditation Teacher Certification, and has completed training in mindfulness-based self-compassion.

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