How to reframe impossible choices into doable decisions, using a tried-and-tested framework and a simple power mantra.

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Have you ever had to choose between protecting your team and

protecting yourself and it really didn't feel like a choice at all?

And maybe you've been told that, well, you always have a choice and

you just felt like punching somebody.

And if I'm honest, in a lot of the keynote talks that I do, I do tell

people that you've always got a choice.

But I've noticed that even though it's totally true, we always do have

a choice, it doesn't seem to help.

As a mother, I have a choice about whether I go and pick up my daughter

from her netball match late at night.

I, I could just leave her.

It is a choice, but of course I'm not gonna do that.

It feels like I don't have a choice.

And sometimes when we are really struggling, when we know we always have a

choice, but still we are choosing to carry on doing those things that are edging

us towards burnout rather than drawing boundaries or saying no, it just becomes

another thing to feel guilty about.

And so today I just wanna unpick why this phrase, you always have

a choice, can be so problematic, particularly for professionals in

high stress, high stakes jobs like healthcare, where you feel responsible

for everybody and everything, and genuinely the buck often stops with you.

This is a You Are Not a Frog quick dip, a tiny taster of the kinds of things we

talk about on our full podcast episodes.

I've chosen today's topic to give you a helpful boost in the time it

takes to have a cup of tea so you can return to whatever else you're

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There's been quite a few occasions in the past year where I've been up till

midnight putting the finishing touches on a project that really, really matters.

It's going live the next day that that one of my team could have done, but it

wasn't quite right and I needed just to make sure that it was perfect because

I wanted to make sure that what we were trying to say really landed right.

And I would say to myself, well, this is my choice.

This is my choice to stay up to midnight doing this.

But actually, it didn't really feel like I had a choice.

Because I really care about my work and I care about what I say to

people, and I care that it's right.

So my choice was just leave it and let it go out when it's not

finished, when it looks bad.

Or I could wake one of the team up and say, well, you need to sort it out.

And that just didn't feel right because I didn't wanna let people down, and I didn't

wanna put extra pressure on my team.

And the thought that I was causing extra stress for other people

just didn't wanna live with that.

So even though I knew I had a choice to leave it, it wasn't really a choice.

It was an impossible choice, because that option came with a massive dose of shame.

And if I've learned anything through doing this podcast,

we'll do anything to avoid shame.

So even though you always have a choice is technically true, I would challenge

this, and I would say actually for doctors and people in high stress, high

stakes jobs, lots of choices come really loaded with guilt, fear, and shame.

So the choice just doesn't feel available to us.

These are impossible choices.

Things like protecting my time versus protecting my team's time,

or protecting my energy versus meeting my patient's needs, or even

keeping harmony and peace versus causing problems and raising issues.

And so when the option to protect myself triggers shame, my brain just falls under

not an option, that is not a valid choice.

And so you choose the patient or the team, or the deadline over yourself, even

if the cost is burnout in the long run.

So I'm calling these impossible choices.

Now, an impossible choice is a decision, it looks binary, because

one option comes with a massive threat and your nervous system just won't

tolerate that threat in the moment, mainly because of your programming.

As a doctor, as a healthcare professional, as a senior leader or

manager, somebody who always helps people, who's always the good one,

who never, ever dumps on colleagues.

And, and side note, in the work that we do, we found that the, the

one thing people fear more than anything is the impression that

they are dumping on colleagues or shirking their responsibility.

Now the threats to our nervous system of these impossible choices

fall into three main categories.

Firstly, it's, it's the harm, threat of harm.

So somebody might get hurt or somebody might be inconvenienced or even just

made to feel a bit stressed or tired.

And we fear this.

We fear causing hurt or harm to other people, and we

feel really guilty about it.

There's then the social threat, the threat of being judged, misunderstood,

rejected, blamed, all that stuff that goes with people pleasing, you know,

trying to maintain a good oppression.

And I've talked about this before, but I recently realized that people

pleasing is in fact more like trying to control somebody else's

opinion of me, and as a doctor, as a professional, other people's opinions

of me, well, that's really valuable to me and that's really important.

So if that is in question, then I might feel a little bit of shame.

I'll feel guilty if I've hurt somebody.

So you've got the threat of harm, the threat of being

disliked the social threat.

You've also got the threat to your identity, the threat that says, well,

I'm not a good doctor if I do that thing that's going to protect me.

And that leads into I'm not a good person, I'm not good.

And that leads to a lot of shame.

And shame is absolutely toxic.

And like I've said earlier, we will do anything to avoid shame.

And if you just add into the mix a massive dose of time pressure, then this

all becomes just too much to cope with.

So this really, really matters.

Because if we just keep telling ourselves, well, I've always got a choice.

I've got a choice, Why aren't I taking the choice that I know I need to do?

Well, we just have more self blame, more shoulding on ourselves and we

just fall into the same old patterns.

But if rather than saying to ourselves, well, I've always got a choice, we

say to ourselves, actually, this feels like an impossible choice, we can

then identify and work with the real drivers underneath it, work out what

the real problem is, and then we can fix it, then we can get some options.

You see, I know that doctors would actually often rather burn out than

pay the short term shame tax of protecting themselves and tolerating

those difficult emotions that come with going against your programming.

So we need to take these impossible choices and we need to turn them

into choices we can actually do.

So.

How do we do this?

Well, I think there are three main steps.

The first step is to spot it and name it.

So the telltale signs of you facing an impossible choice are you feel

like you're backed into the corner.

You feel like you're in your sympathetic nervous system zone when you are

in fight, flight, freeze, or fawn.

You've got adrenaline racing around your body, you can't think

straight, every decision becomes very, very black and white.

You feel anxious.

You might feel your heart beating fast.

You might just feel incredibly stressed, or you might feel like you are very,

very calm, but actually underneath you're simmering, or you might find

yourself fawning, becoming over helpful.

And this is a response I've noticed that lots of us go into.

You know that you are facing an impossible choice when everything feels very,

very binary, very black and white.

And that's actually a hallmark of being in your fight flight or free zone.

The hallmark of being in that threat amygdala hijack zone is that your

thinking becomes very black and white and you cannot think outside the box.

It's actually quite difficult to be empathetic as well.

And actually that is quite useful 'cause if there's a line running towards you're

about to eat, you, you don't need to be empathetic towards the line or thinking

outside the box, you just need to leg it.

So what's happened is that your brain has, uh, sent the blood to your big muscles so

you can run away, so you don't actually have as much energy and fuel in your

brain to be able to make good decisions.

So you get this very binary thing of either I stay late or the patient suffers,

or either I do it or I'm dumping on my team and everybody else have has to do it.

Or I'm on call.

Therefore, it is definitely my responsibility and if I leave

that thing, then I am shirking.

So number one is just to recognize this is an impossible choice moment here.

My options have suddenly shrunk.

And there'll be lots of things that we are doing to ourselves to make

this seem like a very binary choice.

And I've talked about the overwhelm amplifiers before, but these are part

of our programming again, we feel very responsible for everybody and everything,

even when we have no control over things.

We have been programmed to think that we are superheroes, that we can actually

cope with more than other people.

We don't need as much sleep or as as much rest.

We don't need to take breaks, have lunch, all those sorts of things,

which as we know is absolute nonsense.

We've also been programmed to be really, really nice.

So we'll avoid conflict, we'll avoid upsetting people.

We've been programmed to think that the harder I work, the more successful

I'll be, and that everything has to be perfect, because let's face it, we've been

judged by our outputs all of our lives.

So a lot of these things, they're real strengths, which mean that

we can do very difficult jobs, but often these are kryptonite.

They are our biggest strengths and our biggest weaknesses.

So one of the ways that this shows up for me is when something comes up and

needs doing really urgently and it's not really my job, but I know I can do

it, I think to myself, well, I can't possibly leave this or disturb one of

my team when maybe they're not working or it'll mean their, their day is really

disruptive, even if it is their job.

I can't possibly inconvenience them and make them overwork

or stay late because of me.

So I go into that rescuing, that protecting mode, which isn't helpful

for me, isn't helpful for anybody.

So when you have spotted that you are in an impossible choice situation,

you then need to name the story that's going on underneath it.

So is it one of the overwhelm amplifiers, like conflict avoidance or the rescuing

mentality or the superhero delusion?

You can ask yourself, you know, what story is making this feel impossible?

What's underneath, what's my programming here?

The things we hear all the time for people in our training sessions is, well, if

I don't do it, no one else will, if I'm saying no, I'm letting people down, and

if anything goes wrong, it'll be my fault.

So hear the, the rescuer and the superhero in all of that.

The other thing we hear a lot of is, if I don't do it now, I'll

just have to do it tomorrow.

That's the urgency trap where everything feels urgent and important.

And actually in that scenario, we think that the same amount of work when we're

depleted at the end of the day is going to yield the same results as doing

something when we're fresh in the morning.

And of course it's not.

So that binary thing really doesn't work.

The other question you can ask yourself if you want to uncover

these stories is, you know, what am I protecting here at my cost?

So am I protecting my team's wellbeing or my reputation?

And am I really in control of that?

Is that even possible?' Cause the next question is, what is in my zone of power?

And the zone of power is just one of the shapes we use in our shapes toolkit.

It's a simple circle on a piece of paper that tells you what's in your

control and what's not in your control.

So everything in your control goes in your zone of power and

everything outside of your control goes outside your zone of power.

Now I would say that the wellbeing of my team is pretty much outside of my control.

' Cause there's so many factors that I can't influence, but yet

I feel very responsible for them.

And doctors and high stakes professionals, we very good at feeling very responsible

for stuff that's totally outside our control, like waiting lists,

like funding, like company policy.

Nothing we can do anything about, and we feel guilty about that.

And I've done, uh, lots of podcasts about this and one of the things I

suggest is we stop feeling guilty about stuff we can't control, and we

maybe change that to feeling guilt ish.

You know, I care deeply about it, but I can't carry it.

It's not my responsibility because it's not under my control.

So a great question to ask yourself when you wanna name this story and spot the

am I feeling guilty about something that I can't control?

And if it is outside my control, what is the responsible action?

You know, maybe I can document it or let somebody know.

Now if it is in your control, the next question to ask is,

well, do I even have capacity?

And yes, you could try and slot in every single person that wants

a bit of you, but you can't.

So you need to decide what you're gonna focus on.

And one of the things is to get really clear about what your role is.

You know, saying, well, is this actually my job to do?

And many of us work in jobs where our roles are really, really muddy

and we don't actually know what we're expected to do and what we're not,

so getting clear on this could be one really helpful action you could do

because just taking everything on that's, that's over responsibility.

And it often masquerades as professionalism, thinking well,

I'm the only person that can do this, are you, are you really?

And so one question to ask, which can be quite helpful is, am I doing this

because it's mine or just because it's really uncomfortable to hand it back?

See, I think as doctors and senior professionals, we unconsciously

take the default responsibility for many, many things.

And side note, I realized this recently when I've been really

thinking about boundaries and why doctors have trouble saying no.

And sometimes I realize they have trouble saying no because they never

actually said yes in the first place.

Stuff has just landed on them and they've unconsciously assumed the

default responsibility so they never had the opportunity to say no.

So by the time they want to actually lose that task or not do that thing,

it doesn't just feel like saying no.

It feels like an absolute abdication of their responsibility.

And as I said earlier, shirking responsibility, dumping on

colleagues is almost one of the seven deadly sins of being a doctor.

So just asking yourself, well, what part of this is mine and what

part have I just unconsciously picked up can be very helpful.

And then finally, when you are spotting it.

And naming it.

You could ask yourself, well, would somebody else with different

programming to me think that this was an an impossible choice or not?

I remember once I was having my nails done at the beauticians and

halfway through this woman ran in and she was in floods of tears.

She was almost hysterical.

And, um, the lady doing my nail, she got up and she said, well, how can I help you?

And this woman said, I'm getting married tomorrow, and the person that was supposed

to do my waxing has just canceled on me.

What am I going to do?

And, you know, she was in a real bind and I could see that, um, the

lady doing my nails was, was really compassionate and empathetic, and

she said, I'm so sorry, that's awful.

She said, let me see what I can do.

So she looked at her list for the day and she saw that it was totally full up.

And she said to the lady, I'm so sorry, but I don't have any space.

You could try my colleague down the road, but I can't fit you in.

Now.

It made me think, well, gosh, if, if that was me, if that was a surgery

and we had someone come in with a pretty trivial problem, we would

just feel like we had to fit them in, like we'd automatically taken on the

responsibility for this person's issues.

Whereas my beautician, she, she didn't feel like that.

She appropriately took responsibility for seeing if she could help, and when

she realized she couldn't, she didn't take on the responsibility for that.

Now, uh, it has a happy ending this story because, uh, I actually said to

this lady, look, I've got something else, but, but you can take my slot.

Your knee is much greater than me.

And, and it, and it all got done, it was fine.

But it really struck me the way that this person was really compassionate,

really empathetic, yet still did not take on that extra responsibility and

try and fix it and try and rescue things 'cause it just wasn't hers to take.

So if you think of my beautician, you know, if they had that programming

as opposed to the doctor programming of I must help every single person

that I come across, no matter how important or trivial their needs

are, would they be experiencing this as an impossible choice or not?

So that's the first thing.

Spot it and name it.

The second step is to get informed consent from yourself.

So what on earth am I talking about?

Well, before you do any procedure or an operation, you make sure that you

get informed consent from a patient.

So you make sure the patient has capacity that they can understand

way up and communicate decision.

You make sure the choice is voluntary, it's not made under pressure,

and you make sure it's informed.

So you've talked through the benefits, the risks, the alternatives, and

even the option to do nothing.

You also need to know what really matters to the patient.

They need to be given time to think about it, to ask questions.

And also there's this thing about ongoing consent.

You check in again, you don't just assume that 'cause they said yes once.

It keeps going.

Now if we did consent with patients, the way that we do decisions with

ourselves would be struck off.

So can I suggest that when you're faced with an impossible choice,

you run a self consent conversation?

So first one, capacity.

Now we're not talking about capacity, do I have time?

Capacity, as in mental capacity.

Am I in any fit position to actually make this decision right now?

Because if I'm in a corner in my sympathetic zone, everything seems

urgent, my decision making is warped.

I'm not at my best here.

Taking a pause will be your friend.

Getting back to baseline, making sure I'm in the parasympathetic

zone before I do anything else.

Secondly, is it voluntary?

This impossible choice I'm having to make?

So am I being coerced into making it by myself?

Am I guilting myself into doing the thing that's protecting other people and not me?

So I think that the, the people that put the biggest pressure on us are ourselves,

not necessarily other people, although other people can also make us feel bad.

You know, I can think back to times when I was really ill and the impossible choice

seemed to be letting all my colleagues down or, or going off sick and looking

after myself, and did my colleagues say, oh, Rachel, you should just go off sick?

No, they didn't.

Of course not.

They wanted me around because it just meant more work for them.

So there is this nagging coercion by ourselves and by other people, by feeling

guilt, by feeling shamed by this identity as a good doctor, fear of judgment, and

yes, sometimes this workplace culture.

So one helpful thing is just to name this explicitly.

So say, well actually I'm not freely choosing this, i'm being

pushed by fear of looking lazy, for example, or being, I'm being pushed

by fear of letting people down.

Now the next step is to be informed and give yourself the time to

consider all the information just like you do with the patient.

So you need to look at the risks and the benefits.

Now one structure that people use for talking about risks and benefits for

the with patients is the BRAN framework.

It's a framework developed and used in shared decision making.

And we'll put links to it in the show notes.

But BRAN just basically stands for benefits, risks,

alternatives, and nothing.

So firstly, you look at the benefits.

If I make this impossible choice, right, what are the benefits?

It might be, you know, actually we genuinely keep somebody safe, we

genuinely avoid a big clinical disaster.

So what improves, who is helped, what risk is reduced?

Now we are really good at seeing this.

We are really good at seeing the benefits of sacrificing ourselves, right?

We are not very good at the next bit are for risks.

So say if I'm being asked to say late do, to do something extra and I can

see a, a clear potential benefit, but I'm not really looking at the risks.

And it's not just the risk of, well, I'm gonna feel tired, but there's also

some other risks such as, well, I might, might make some bigger errors tomorrow.

I'm gonna have reduced empathy with people.

I might be becoming unsafe, there might be strain in my relationships at home.

All those things.

And this is where it gets really tricky because the short term difficulty,

the short term harm, often shouting at you in the face, whereas the

long term stuff, it's a bit more difficult to put your finger on it,

but here's some things that might help so you can reality test your fear.

So when you can see a real risk right at the beginning of something that

might happen, immediately, we need to start thinking about the consequences

and, and think, well, what's the actual consequence and how likely is it to be?

One of my most popular keynote talks is all about how to say

no when someone might die.

And if someone might genuinely die, then you probably wouldn't say no.

But I've asked hundreds and hundreds of people what stops them saying no, because

the the reason most people trust how it's, I can't say no because of patient harm.

And I've put this to the test, I've done lots of Zoom polls, or if it's

face-to-face, we've done sort of standing up or raise hand polls.

And in all the time I've been doing these polls, less than 20% of people

have said that actually the reason they can't say no is because of patient harm.

Most people say it's because they're frightened of what

other people might think.

They don't want to inconvenience people or they would just feel far too guilty.

So we often catastrophize things, say, well, if I don't do this or if I don't

make this impossible choice, it's gonna, everything's gonna go really, really bad.

But actually think about, you know, how often has that happen and how

likely is that to happen really?

And actually what are the likely consequences?

'cause if the likely consequences are, you know, really serious, then you are

gonna probably have a low threshold for trying to avoid those, right?

You know, and dreadful patient harm we really want to avoid, but maybe someone

having a slightly lower opinion of you, well, that's not quite as bad, is it?

We can probably learn to tolerate that.

So I always say in my, how to say no set boundaries and deal with pushback

talk, I think the question isn't, how do you say no when someone's gonna die?

It's how do I deal with my own people pleasing perfectionism

and fear of complaints?

So first of all, just like reality test what the consequences might be.

Secondly, think about your own values.

You know, what do you want to be able to say about this later?

And this really helps when both options feel really awful, like letting your

team down feels awful, but also letting yourself and your family down feels awful.

Think about what choice would align with the doctor or the leader.

I really want to be?

And perhaps even what would I write in the notes or, or explain at an

incident review what's the most defensible and self-respecting option?

And another thing I like to ask is, what would the future me thank me for?

Would they thank me for just caving in and going with my amygdala response?

Or would they thank me for actually choosing to protect myself?

And this leads on to the next question that you can ask yourself.

Here's what am I trading away if I say yes.

And these are hidden trades that aren't obvious at the time.

So being fresh for tomorrow's clinical presentation or making good decisions for

the rest of the week, time with my family, the people that are most important to me.

And I recently heard the term residual beneficiary, and for many,

many of us, our families, the people that are most important to us in

the world are just the residual beneficiaries of our time and attention.

Do I really want my family, my partner, my kids to feel like that?

No, I don't.

So I might be trading the relationships with the nearest and dearest people to me.

I might be trading my sleep, So something you can ask yourself,

well, if I do this, what will I not do, and is that acceptable?

The other thing we need to think about is what precedent, what

pattern am I creating here?

And you might talk a really good game about setting boundaries, about

self-care, about looking after yourself, but senior people, you teach the system

what is normal by what you absorb.

So if your juniors can see you staying late, absorbing everyone else's stuff,

guess what they're going to learn.

Guess what they're gonna think is normal and the way ahead.

And if you always rescue people, the system just gets groomed

to expect you to rescue them.

And if you always stay late, the organization just really

quietly budgets for that unpaid labor that you're gonna do.

So one thing you can ask yourself is, well, if I do this today, am I willing

for this to become the expectation?

And is this really what I want to role model to everybody else?

So those are ways of working out the risks and the benefits

of these impossible choices.

benefits, R: risks.

Now the A in BRAN stands for alternative.

What alternatives do you have?

Because when we're in the corner, when we are faced with these impossible

choices, it feels like a binary decision.

But there might be a third way.

There might be a third option that we just can't see at the time, and

this might be much, much better.

For example, if I think about that time when I was up till midnight putting

the final touches on a, a website page before we launched a new product,

something I could have done is just think, well actually what is good enough?

What is good enough and done?

Because we know that good enough and done is better than perfect and pending.

How can I lower the bar?

Or you could ask yourself, well, what little bits are the real deal

breakers that need to be done now?

And what can wait?

Or what's the minimal help I can give that's gonna really help that person?

Or if you're feeling like, well, I've gotta do things now because otherwise I'll

just have to do them tomorrow, you could ask, well, what are the real deal breakers

that you need to do now, the really important stuff that will mean you can

get home and leave till tomorrow where a lot of stuff may have disappeared, or you

might be able to think outside the box and think how you can delegate it, get some

help with it, or even drop some of it.

So the N in BRAN stands for nothing, no action.

So what happens if I just don't make that impossible choice?

Because I'm sure you've been in a situation where you've thought something's

really urgent and really, really important, and then something comes up

like one of your kids is ill, or you've got to go to hospital or there's a, a, a

real family emergency, and you just drop the work and you go off and do that, and

actually nothing bad really happened.

So if we can do that when there's an emergency, then we can do

it at other times as well.

So that BRAN framework, thinking about the benefits, the risks, the

alternatives, and what happens if you do nothing, that will really

help you with your informed consent.

But if you think about consent with patience, consent isn't a one-off

signature, it's ongoing, and and patients get time to consider things.

So you might need to give yourself some time or even get a second

opinion about this decision.

So for self consent, you might wanna think to yourself, well, can I decide in

10 minutes rather than now, give myself a pause, give myself time to get out

of the corner, out of my sympathetic threat zone and back into rest and

digest where I can make better decisions?

And you could think, well, who can I really reality check this with?

Do I have a colleague, a partner, a clinical director, or, or just

a good friend that I can run this by and get a, an unbiased opinion.

And then of course with patient consent, they can withdraw

it whenever they want to.

You mustn't assume ongoing consent, and I think this could be a real game changer.

Now, one of my real values is when I say yes, I mean yes,

and when I say no, I mean no.

But sometimes that hasn't stood me very well, because it means I've

persisted with things just because I've said yes in the past, and I think I

need to see it out to the bitter end.

And just because you've said yes once, it doesn't mean that you need to stick to it.

Because to persist on one course of action when it's obviously not

going well for you, it's just madness if you know that you haven't got

capacity and it's causing harm, now that's not flakiness, that is wisdom.

So let's just learn not to put ourselves in shackles by

what we've already agreed to.

It is okay to change your mind.

It doesn't mean that you're a really flaky person, believe me.

So one thing you could do, you could sort of consent to the next 20 minutes,

or you can say, well, I'll do that tiny thing now, i'm gonna revisit this

tomorrow with a fresh brain and take time to review it, get a second opinion.

Because you need to make sure you have got self informed consent, because if

it's not informed, it's not consent, it's just coercion, obedience or compliance.

And compliance, which is done out of guilt, shame, or fear, that

is what's burning doctors out.

So next time you catch yourself saying like, I have no choice.

I've gotta do this.

And pause, take a breath and do what you'd want any patient to do.

Get informed consent from yourself.

Ask yourself those BRAN questions, make a real choice and make one that protects

both you and the people that you care for.

So informed self consent helps you know the risks and benefits,

and helps you turn an impossible choice into a doable decision.

So step three is to reframe this choice into a doable decision.

And this is where you just really widen your options and you reclaim your agency.

And the one thing I have found invaluable over the last few years is to use power

mantras and it just sort of combines everything that we've talked about.

Now, a power mantra is three lines.

The first one is, I am choosing two, or I'm choosing not to.

What are you choosing two or not to do?

So it could be, I'm choosing to go home and not see that extra walk-in

patient that's not really urgent, it could mean I'm choosing not to

volunteer for that departmental project that needs to be done.

What is it that you are choosing to do?

The next line is so that.

What are the benefits of this choice that you're gonna make?

I'm choosing to go home so that I can be re-energized and fresh for that

really long on-call day I have tomorrow.

So we know why we are doing it.

We are looking at the long term benefits, not the short term benefits.

And then the last line that we need, and we mustn't miss this line out, is even

if, like, even if, what is the risk?

What might occur?

What's this short term herd that's gonna put you in the

corner and get you really worried?

Even if my colleagues think I'm dumping on them.

Let's predict it.

Even if I get pushback from people, even if I get a complaint, it brings it out

into the open and it makes it less scary.

And we think, well, yeah, okay.

I probably could cope with a complaint because I know that

clinically that was a safe decision.

And if I'm not fresh for tomorrow, I might make much, much worse decisions.

So putting these things together in power mantras can be really, really helpful.

So I'm just gonna go through a few scenarios, which might help.

First one, it could be an impossible choice of me versus patient safety,

which is that the harm threat.

So it could be something like, well, either I stay late and keep patients safe,

or I go home and someone gets harmed.

That is an impossible choice, right?

No doctor would agree to that.

But let's think what the long-term harm of that might be.

Well, if you keep making patient safety means self-sacrifice, you eventually

become the unsafe variable, you're exhausted, you're slower, more error

prone, and more likely to leave.

So let's think what a doable decision might be.

So that power mantra might be the one that I just talked to you about.

I'm choosing to go home and say no to extra patient tasks so I can preserve

my energy for my on-call day tomorrow and connect with my family even if

there is a small chance that something out of my control might go wrong.

So it's about weighing up the risks and benefits, isn't it?

And you know, we are not advocating putting patients at risk, absolutely not.

If there is a significant risk of patient harm, then of course we

will make sure the patient is safe.

Now the third options here might be you ask yourself, well,

what's the minimum safe standard?

What must I do today to prevent harm and everything else can wait?

Or I'll do a little bit of a safety triage, i'll do the top risk items,

and then I'll hand over everything else, or I will time box the care.

I'll go, well, I can do 15 minutes now safely, then I must stop.

Let's look at another thing that people say to me all the time.

Well, if I don't do it, one of my team will have to do it.

I dump it on my colleagues.

Well, let's look at the risks and benefits.

The long term harm is if you keep rescuing the team, you just become

the bottleneck and the buffer.

Over time, you burn out while the team never builds

sustainable load sharing habits.

So your doable decision might look like this.

I'm choosing to leave this to be done by the rest of the team so that

everybody's taking on their own share of the responsibility, doing what's

on their job description, and I get to my more important tasks, even if

the team feel unsupported at times.

And I don't like the thought that my team might feel unsupported, but actually

that's the letter of the two evils, right?

Here's one about reputation.

So either I say yes and I look like a good doctor, or I say

no and look lazy and difficult.

I'm sure we've all had this.

Well, the long term harm in that is, well, if you keep paying for approval from your

colleagues with overwork, then you're teaching people that your boundaries

are negotiable and you end up trapped and performing the good doctor at the

cost of your health and your home life.

You'll get those residual beneficiaries at home.

A durable decision might look like this.

I'm choosing to make the right and rational decision on this so that I

can protect my time and focus on the other important stuff that needs doing,

even if somebody else is disappointed, Even if my reputation suffers.

That's difficult, isn't it?

To think that my reputation might suffer, but really we can't control

other people's opinions of us anyway.

Let's look at a couple more.

Have you ever thought this?

Well, either I push on through like a proper professional, or I'm just

weak and selfish and can't cope.

The long-term risk.

Well, if you keep proving you're fine, you erode your basic recovery

time and the price shows up later as burnout or compassion fatigue

or needing much longer time off.

So.

There are some alternatives.

You could reframe breaks as patient safety, so rest breaks mean

safer decisions and fewer errors.

And your power mantra here would be I'm choosing to take a proper

lunch break today so that I have enough energy for the tough clinic

this afternoon, even if I don't get everything on my to-do list done.

There's the thing about integrity versus realistic capacity.

So our impossible choice might be, well, I said I'd do it, so

I have to, even if it wrecks me.

But long term, if you keep honoring promises by breaking yourself, you

eventually become unreliable anyway, because your capacity will just collapse,

you can't keep any promises at all.

So your doable decision might look like what I'm choosing to change my mind and

say, I can't do this particular task so that I can fulfill my other more

important and pressing responsibilities, even if people think I'm flaky.

And finally, here's one I think that we can all identify with.

Well, either I do it now or I'm gonna suffer later.

So the impossible choice here is, well, the work is fixed.

If I don't do it tonight, I'm just ruining tomorrow.

Well, if we really look at the risks and benefits, the long-term harm for

this could be well, if you keep saving tomorrow by seeding from your sleep

today, then actually tomorrow gets worse.

Your speed and your judgment and your prioritization will, they'll drop, the

backlog will grow anyway 'cause you are running on fumes, and you can do

things so much better when you are well rested and you'll do things quicker.

So it's not a fixed amount of time anyway.

So the power mantra would be I'm choosing to stop work before I've

completed everything so that I can reenergize and rest and get it done

quicker another time, even if there's stuff that I will have to do tomorrow.

And the alternatives here now are just do a, a tiny slice now and leave breadcrumbs

for tomorrow so you know exactly what you've got to do tomorrow so you don't

have to think and do things twice.

Now, that's a lot, but I just want to introduce to you the concept that the only

way to make these impossible choices feel like doable decisions is to analyze them,

to look at it and go, is that really true?

Have I really got informed consent on this?

And what short term hurts am I trying to avoid by creating

long term problems for myself?

Now there are some mistakes that we can make in all of this.

And firstly, some people just pretend that every impossible choice is

solvable with, with some mindset shifts.

And that's just not true.

Some choices are genuinely brutal, but you want to be really accurate

about the actual consequences.

We don't want to ignore patient safety or proper real, difficult,

important consequences.

But in my experience, it's mostly not about the consequences or patient harm,

it's more about other people's opinions of us and, and feeling guilty for stuff

we're not in, in control of anyway.

The next thing we can do is believing that what our amygdala is telling

us when we're in our threat zone is real, and it's very logical.

Um, doctors are really, really brilliant at sounding very calm and

thinking they're thinking from logic when actually making fear-based

decisions and we're actually fawning rather than being really professional.

Another mistake we often make is just looking at the binary thing.

Often, these third options that is where the, the real relief lives.

And doing it too quick, doing it in the ,moment while we're in our

fight flight of free zones, rather than letting ourselves have a bit

of time to actually consider this.

And if you really don't have time in the moment and you find yourself really

stuck with this, then afterwards debrief yourself, use a journal, talk to somebody

so that next time it becomes easier.

So, if the truism that you've always got a choice actually makes

you feel worse, then don't worry, there's nothing wrong with you.

I find that really difficult as well, because often the choices that

we do have just feel impossible.

And these impossible choices feel impossible because of the shame and

the guilt and the fear price tag.

The way to deal with it is firstly, spot it and name that fair shame or

guilt story, get informed consent, give yourself time, go through the BRAN§§

framework, think about the benefits, the risks, the alternatives, and

what would happen if you do nothing.

Know that you can change your mind, that you need time to think about alternatives,

and shift them into doable decisions by thinking about alternatives you've got,

and using the power mantras where you know that the long term harm is much,

much worse than the short term hurt, and so you are able to make that decision.

There's always gonna be really difficult decisions in life

choices that feel impossible.

And if I've learned one thing recently is that you can't

please everybody all of the time.

The sooner we can start to tolerate other people not totally approving of us,

other people not getting us the better.

But the person we really, really need to learn to tolerate

their disapproval is ourselves.

We need to learn to give ourselves permission to do things that might

trigger some fear, shame, or guilt, but know that the alternative is even worse.

Know that we are doing these things, having really thought about it.

Because we do need to learn to disappoint other people.

Otherwise, we'll end up disappointing everybody, including ourselves.

So you don't have to stop caring about this stuff.

You just have to make sure you are properly informed and giving informed self

consent about some of these decisions, examining them, and then choosing the

doable decision that's gonna keep you well, that's gonna keep you working,

that's gonna beat burnout and helps you enjoy your job again in the long run.

So this week, just notice one impossible choice you are facing,

and when you notice it, do a 30 second BRAN check before you act.

Work out what the benefits, the risks, the alternatives, and

what doing nothing might entail.

And if you want more scripts, practical tools to make these decisions in

real time, then come and join us in FrogXxtra or FrogXxtra Gold, 'cause this

is exactly the sort of thing we like to talk about at FrogFest, our twice

yearly virtual conference and in the monthly hot topic podcast and in the

short videos we send out every month.

So go well, and I would love to hear about some impossible choices that

you've turned into doable decisions in our You Are Not a Frog Facebook group.

Let us know what have you tried, what has worked, what hasn't, and do you have

any other top tips to share with us?

and I'll see you for the next quick dip.