Latest / The Hidden Load: For the educators and leaders in medicine who hold everyone up. / The July Reset: Lowering the Threat Defense on the Wards
Transcript
- Santina Wheat: Welcome to the hidden load for the educators and leaders in medicine who hold everyone up. We will tackle the hard topics and help you conquer your chaos and get to calm all by starting to acknowledge and remove that hidden load. This podcast is a space for us to name the things that are common, but not normal. Each week, we'll look at the invisible weight you're carrying and explore practical coaching-based tools to help you find more calm, better boundaries, and a sense of purpose that doesn't require you to run on empty. I'm so glad that you've carved time out for yourself today. Let's get into the episode. Welcome back to The Hidden Load. I am your host, Dr. Santina or Tina Wheat. If you're listening to this in real time, we have just crossed the threshold into the most exhilarating, volatile, and fragile month in the medical calendar. It's July. Walk onto any inpatient floor, into any ambulatory clinic, or into any operating room right now. And the energy is palpable. The badges are brand new. The short white coats are crisp, stiff, and unwrinkled. We have brand new third-year medical students stepping onto the wards for the very first time, holding their clipboards like shields, trying to figure out where to stand so that they aren't blocking the computers or getting in the way of the residents or the attendings and the nurses. We have Brand new interns realizing with a jolt that their signatures actually carry legal weight now, that the order is theirs, that the patients are theirs, that there is no longer a student buffer between their keyboard and the patient's chart. We have senior residents who are stepping into the role of supervisors or team commanders suddenly responsible for the timelines that they used to just follow. And we also have new attendings sitting in their new offices dealing with a massive wave of imposter syndrome as they sign off on complex clinical decisions without the safety net of a supervisor who was always there to talk it through. It is a season of immense excitement. It represents the renewal of our profession. But for those of us who lead departments, Run residency programs and teach on the wards. July carries a massive unquantified hidden load. The labor of the structural reset. Think about the contrast. Just last month, you said goodbye to a team that you trusted implicitly. You had spent twelve months developing a seamless operational shorthand with your senior residents. You knew their blind spots. You knew that they knew your boundaries and how to talk to you, and the clinical machine had started to run like clockwork. You could give a subtle nod during rounds and the orders were placed before you left the bedside. Now, overnight, the institutional memory is entirely gone. Everything has changed. The slate has been wiped clean, and you're starting from zero again. Today We are talking about how to navigate this cultural reset without burning yourself out. We're going to look at why the first few weeks of July, if not really the first couple of months, are the most critical window for the entire academic year for establishing team boundaries and how to intentionally model psychological safety for teammates who are currently terrified of failing in front of you. So let's start by naming the friction first, because as medical educators, we rarely give ourselves permission to acknowledge the emotional tax of this transition. We experience a very real form of professional grief. We invest our energy, our mentorship, and our emotional bandwidth into our trainees for three, four, or seven years, depending on our specialty. We watch them transform from clumsy interns into brilliant, polished colleagues. And then they graduate and they leave the institution. Right when we are emotionally exhausted from that milestone goodbye, the system drops a completely unpolished, terrified, raw cohort into our laps and says go. There is no downtime. In fact, for many organizations, There's even an overlap. The emergency department is still full, the clinic schedule is still packed, and the system expects the same throughput. The immediate temptation for the busy attending or clinical leader during this transition is to default to survival mode. Because the new team doesn't know the hospital geography yet, because the M3s take 20 minutes to present a history that will take three ultimately. And because the new interns are double checking every single dosage out of pure panic, the clinical day slows down and often feels like it slows to a crawl. The systemic friction spikes, and when friction spikes, the overfunctioning trap snaps shut on the leader. You think to yourself, it's just faster if I write the crosscover note myself. It's safer if I call the consultant instead of making the new resident do it. But does that really help? Let's look at a case study of how this might unravel. Imagine a Tuesday afternoon in July, the team is woefully behind on rounds. The new intern is struggling to enter a discharge order set. The senior resident is getting frustrated because the pharmacy is rejecting a presentation format. And as the attending, you feel the walls closing in. Your cortisol spikes, you grab the mouse, pull the keyboard away from the intern, and say, move over, I'll just do it. But what did you actually accomplish in that moment? Well, sure, you close the chart faster, but you paid a massive long-term tax. You absorb the system's learning curve with your own biological time. More importantly, you missed the critical window to build capacity. July is not a month to survive. It is a month to set the container. The operational boundaries that you draw, the communication habits that you tolerate, and the culture that you build in these first few weeks will dictate the efficiency, the safety, and the burnout rates for your team for the next academic year. You cannot afford to let a new team inherit a default culture of panic and micromanagement just because you are tired. And don't get me wrong, I understand that it's exhausting, but the work that you put in here can really help set the stage for the entire year. Let's look at the neurobiology of your new teammates right now. Whether it's a brand new attending or a third year medical student on day one of their internal medicine rotation, every single one of them is operating with a hyperactivated threat defense system. Their amygdala are running the show. They're completely paralyzed by the fear of looking incompetent. In a medical culture that has historically been shame based, Not knowing is interpreted by the brain as an existential threat to their survival in the profession. When people are terrified of looking stupid in front of their leader, they do highly dangerous things. They hide their clinical mistakes. They don't ask for clarification on ambiguous orders, and they just nod their heads yes when you ask if they understand, when in reality they may have no idea what you just said. As the leader, your primary operational directive in July is to dismantle that threat defense system. You do this through what I call the vulnerability dividend. You have to be the first one to take off the armor of the all knowing expert. If you want your residents to tell you when they are drowning, you have to show them what an authentic, healthy relationship with limitation looks like. On day one of a new rotation, During the very first team huddle before you even see a patrant, I want you to explicitly state the rules of engagement. Don't give a generic speech about excellence or keeping up with the metrics. Give a speech about reality. Look at your team in the eye and say this verbatim. We are a brand new team, and that means we are going to experience friction this month. We are going to make mistakes. The system is going to throw us curveballs. And there will be moments where none of us, including me, knows the immediate answer. My expectation for this team is not perfection. It's about absolute transparency. If you don't know something, it's okay to say it. If you feel uncomfortable with an order that I give, I want you to ask about it with curiosity. And this space, an I don't know, is a valuable data point for learning, not a character flaw. When you explicitly state that imperfection is an expected budgeted part of the workflow, you instantly lower the baseline cortisol in the room. You create psychological safety by explicit design, not by accident. You pay a small ego dividend up front to buy massive team accuracy, trust, and long term clinical safety. The second part of the July reset is establishing behavioral boundaries for how your team manages their own hidden load. Remember our core principle, your learners are absolute sponges. They are learning how to exist in medicine, not by reading our wellness policies, but by watching our daily habits. If you don't teach them how to protect their cognitive energy now, they will learn to white knuckle their way straight to burnout. And so I want you to introduce two specific operational boundaries to your new team this week. The first is explicit expectation routing. Do not let your interns or residents waste mental bandwidth guessing what you want. Perfectionists wastes massive amounts of cognitive energy trying to read their attending's mind like a psychic riddle. Tell them exactly how you want the information delivered. Say When we round, I want a three-minute synthesis focusing on the diagnostic pivot and the active plan, not a 15-minute chronological text dump of the entire chart. I value your clinical synthesis over your data volume. By bounding the expectation, you lower their cognitive load and give them a clear metric for success. Another example might be: when you present the patient from the clinic. I want you to give me the full history and physical. I want you to share all that you've gathered so that I know what you've gathered so that we can learn and minimize what you have to tell me next time. The next operational boundary is the off duty permissive clause. This is where we actively combat pajama time for the next generation of physicians. Give them an explicit directive regarding digital communications. Say, I do not expect you to log into the portal outside of your clinical shifts. When you are off, your primary clinical duty is rest and recovery. It might be reading about a patient that you saw, but you don't need to open the chart to do that. If something is an acute safety issue, I or the chief will call your phone directly. If you see an email from me at 9 p.m., it is because that is when my schedule allowed me to write it. It's for the next day, it's not for tonight. I tell my residents that before a clinic visit, I think it's helpful to pre-chart, but I give them a specific time limit. I say, I don't want you to spend more than 30 minutes previewing the charts for that day. And as you get faster, you'll be able to review faster. But I give them a specific time frame because I've seen it happen. Like people spend two hours reviewing charts and they learn to have time pajama time built into their days and have so much burnout from this as they continue. When you can speak the words out loud and give clear expectations, you lift a massive invisible weight off their shoulders. You are rewriting the unwritten rule of medicine that says to be a good doctor, you must always be available to the system. And then finally, the feedback blueprint. In July, you will have to correct mistakes. But how you correct them matters. If a new intern misses a critical lab review, do not launch into a lecture on diligence. Instead, I want you to use the growth feedback protocol. First, you have to start by establishing the shared goals. We both want to ensure that our patients are safe. Second, state the observation, but without drama. The tap The potassium level wasn't checked before the morning dose. Third, ask a diagnostic question. What broke down in the morning workflow that caused this to get missed? By treating the mistake as an operational bug to be solved, rather than a personal failure, you're able to maintain safety while accelerating their learning curve. Even if you do this perfectly, that doesn't mean that they won't take it personally. But when you can support them and teach them that this is okay and not a criticism of them as an individual, then it can really help them grow. Now I want to pivot and speak directly to the senior faculty, the department chairs, and the program directors listening. And I'll say more of you are senior faculty than you think. Let's look at our new attendings this month. We spend so much energy focused on the students and the residents that we often completely forget the most fragile transition in the entire pathway. The jump from senior resident or fellow. To first year attending is arguably one of the most abrupt, isolating transitions in a physician's career. Think about the psychology of that shift. One day you're a trainee with the supervisor validating every choice, checking every note, and acting as your ultimate safety net. The next day, you're the final signature on a legal document that dictates a human life. That's heavy. The hidden load of the new attending is what I call the silence of autonomy. They're frequently drowning but they feel they can no longer ask for help because they have arrived. They may believe that asking a senior colleague a question means that they are exposing themselves as unqualified for the badge that they just earned. They sit in their clinics or their offices after hours, overthinking every order, terrified of making a mistake in a silo. As senior leaders, our job this month is to actively reach out and bridge that isolation. Don't wait for a new attending to come to your office with a crisis or clinical error. Walk down the hall, knock on their door, and give them safe space to debrief. It's better if you can avoid the generic how are things going, because many of them will just say fine. Instead, ask a specific question: what was the most frustrating administrative hurdle you ran into this week? You can share a story of a mistake that you made during your own first year as an attending and show them that true professional competence isn't about working in an isolated silo. It's about continuing to use collaboration as a clinical safety net. If we want them to survive the mid-career squeeze 10 years from now, we have to teach them how to seek support without shame today. Okay, we have covered a lot of ground today in a short time. We talked about the professional grief of saying goodbye to old teams, the biological necessity of lowering the threat defense system for our new learners through the vulnerability dividend, the tactical scripts for bounding the shift. And the unspoken isolation of our new attendings. And so your Monday morning challenge, when you walk onto the floors, into the clinic, or into the department this week, I want you to look at your new team through an operational lens. Don't just see their titles, their schedules, or their task lists. I want you to see their nerves. See their profound desire to do well. And see the heavy weight of the perfectionism that they are already carrying on day one. I want you to take five minutes before the clinical block begins to explicitly set the container. Gather your students, residents, and the staff. Tell them what you value. And that it's their transparency over their perfection. Give them explicit permission to log off when their shift ends. And model the exact boundaries you wish you had been taught when you were standing in their shoes. Right now, you have a brief golden opportunity to completely rewrite the baseline code of medical culture for this new cohort. Don't let it slip away into survival mode. Protect the person, protect the team. And you will protect the mission. Thank you for listening to the hidden load today. I'm Dr. Santina Wheat. If this July reset breakdown resonated with you, I hope you will share it with a fellow educator, chief resident, or new attending who might be carrying a bit too much weight today. Let's lighten the load together, and I'll see you next week. Thank you for listening to The Hidden Load. If today's conversation spoke to you, I would love for you to share it with a colleague who might need to hear it too. It's one of the simplest ways we can start shifting the culture of medicine together. And remember, your time spent reflecting here matters. You can earn free CME or CE credits for listening to today's episode through the Pinnacle app. You'll find that link in the show notes. If you are looking for one-on-one coaching support or want to dive deeper into the resources we discussed today, let's connect. You can find information on how to reach me in the show notes. don't forget to hit subscribe so that you never miss an episode and leave me a rating so that others can find me too. and take care of yourself because you deserve to be held up to. And I'll see you next time.