Physicians Anonymous

Cognitive distortions in medicine

Cognitive distortions in medicine – part 1

In this article, we define cognitive distortions with the intent of showing how unrealistic and unhelpful these thoughts actually are. Extreme stress tends to bring out more of these cognitive distortions, and modern medicine is a rich source of stress for doctors and medical students. We give 6 examples of classic cognitive distortions as applied to medicine, and discover ways to challenge them with more realistic thinking.

The human mind and its programs

Our combined brain power took us out of the trees and, within a few short millenia, into space. (Human minds also invented Agent Orange, subprime mortgages, leaded gasoline, and spam email. So it’s not all roses).

The human mind is inconceivably and breathtakingly complex. The seat of the mind, the brain, contains roughly the same number of neurons as there are stars in the Milky Way galaxy, around 100 billion, which when interconnected, results in 1015 neural connections. 

These connections allowed us to out-think and out-compete our predators and become (for better or worse) the dominant species on this little blue planet. 

Our combined brain power took us out of the trees and, within a few short millenia, into space. (Human minds also invented Agent Orange, subprime mortgages, leaded gasoline, and spam email. So it’s not all roses).

What are cognitive distortions?

We also developed a bunch of ways of thinking (‘programs’) which, from an evolutionary and developmental perspective, were advantageous. They helped us avoid danger (= getting eaten by a predator before our genes could be spread), procreate (=spread out genes), find patterns (=save on thinking = brain energy), and so on. 

Yet for all its amazingness, these mind programs, when running too energetically, can cause the user issues. The extreme of this is of course mental illness, but long before one becomes ill, we can identify a number of thinking routines which, frankly, don’t stand up to reason. We call these irrational beliefs ‘cognitive distortions’. 

In extremis, and particularly in stressful situations, these patterns may become particularly unhelpful. Modern commercialized revenue-based or resource-poor medicine is a prime cause of extreme stress in those who work in it. More than 6/10 of US physicians are burned out, and burnout is caused by sustained, immense, stress. 

You may recognize some of these in yourself:

You are doing more good than you realize. Own it. It’s yours.

1. Disqualifying the positive

Classic examples we have heard in our Physicians Anonymous 1:1 coaching sessions (and the way to challenge them) are:

  • “The patient survived, but it was luck, not my skill that did it.”

Indeed, luck may have played a part. But far more likely is the skill, dedication, hard work, and evidence-based medical science which you applied so skillfully.

  • “It was pure luck and not hard work that got me into med school/ residency/ /this awesome job”

This discounts the years of study, sweat, and tears that you invested in getting to each of these stages, passing the selection tests which are barriers to entry, and progressing along the extremely challenging medical career pathway. You are, in fact, hard working and bright. You deserve this job!

  • “That diagnosis was a guess”

This cognitive distortion discounts years of training in pattern recognition, picking up subtle signs, and often unconsciously forming correct diagnostic conclusions. You are doing more good than you realize, Own it. It’s yours.

2. Personalization

“The patient died because of me. It’s all my fault.” 

Interesting how we attribute bad outcomes to ourselves, but good outcomes to luck? 

In reality, when someone reaches medical care, they are sick and there is a chance of death. Unless you actually messed up (and if you are not sure, it’s important to check it out with a trusted colleague or supervisor), the patient was sick before you got there. 

More realistically: 

They may have died anyway. Illnesses are unpredictable. Modern medicine has its limits. There are so many complex factors: my role was just one of them. 

And even if you made a mistake (and as a conscientious doctor, you will learn from it and not make it again), I may be good but I’m not perfect. I am human and humans make mistakes.

3. Generalization

“All alcoholics are difficult patients; all orthopedic surgeons have the lowest IQs of all physicians; all psychiatrists are a insane” 

When you see that in writing you can see how it does not stand up to reason. In fact, an excellent BMJ study on the IQs and grip strengths of  orthopedists vs anesthetists debunks that one. 

The point is that humanity is a spectrum disorder. There is a wide variety of IQs, EQs,  affability, and dexterity across medicine. Stereotypes don’t help us, and in fact may worsen outcomes. 

4. Negative mental filter

“I am terrible at pediatrics/teamwork/coping with stress.” 

This is focusing on the negative, such as the one aspect of a job which you dont’s (yet) excel at. The reality is that life (and medicine) are journeys. We make progress. Sometimes we fly, sometimes we fall. But we pick ourselves up and carry on. 

Further reality check: statistically you are most likely somewhere in the middle of the normal distribution curve of achievement. 

And besides, do you need to be top of the class at everything? Is good enough, enough? Is mediocrity not an admirable aim?

5. Jumping to conclusions (or mind-reading)

“The Attending thinks I’m an idiot.” 

We may be pretty smart and good at lots of things, but we cannot read minds. We can misinterpret people’s facial expressions, words, and body language. The attending may be scowling, but you are probably not on their minds. Their 50 acute patients, mortgage, research project, or spousal argument are more likely.

Maybe the Attending’s scowl was because they themselves were having a bad day, or they’d just had an argument with a recalcitrant Radiologist. 

It’s not all about you. And you cannot read other people’s minds.

6. Should-ing and must-ing

“I must get this research published. I should be better at this by now.” 

This is using language that is self-critical that puts a lot of pressure on ourselves. In reality, the chances of publication are mostly random and out of our control. Publication depends on the moods and conflicts of reviewers and editors, what’s topics, and a thousand other variables we can’t control. What we can control is the quality of what we write, and getting the manuscript proofread for typos.

Similarly, exhaustion is normal when you are working so many hours, taking so many people’s lives in your hands, making life-and-death decisions, enduring high cognitive load and sleep deprivation, And that’s before you have a life outside of medicine.

Conclusions: cognitive distortions in medicine.

In this article we have explained the concept of cognitive distortions and given examples of these which may be familiar from modern medicine. We have also given a reasoned reframing of the thinking into (hopefully) more helpful and less self-critical approaches.

We hope that this has been helpful.

Watch out for the next instalment in Part 2, where we look at black-and-white thinking, fortune-telling, and catastrophizing (my personal bugbear).

Thanks for reading.

PS – if you think some cognitive reframing may be helpful, please consider engaging a Physicians Anonymous accredited coach. They will know all about these and how to tackle them in your life. Coaching is proven in multiple trials to improve wellbeing, including in medicine. It can enhance your career, too. And coaching does not need to be declared as it’s not mental health treatment.

Further reading: How to recognize and tame your cognitive distortions (Harvard Health Publishing, 2022)

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