Permission.

A few days away from the end of my three-week rotation on the dementia unit. My attendings have been inspiringly warm and upbeat, I keep far more normal hours, and nobody makes me feel stupid. I wouldn't call the experience "rejuvenating" by any means; in fact, it's been a pretty dismal scene. So dismal that it only took me 14 hours before I completely wrote off my half-baked (but nevertheless present) ideas about dual residency in family medicine and psychiatry, once it became clear that I wasn't especially stoked about even my 15th hour.

I was tempted several times throughout this rotation to write. In theory, this was a "big deal" rotation for me (as a point of irrelevant trivia, I originally went back to school to do my pre-reqs and apply to medical school towards the specific pursuit of a career in psychiatry!). And there were quite a few "big deal" moments -- some painful, some overwhelming, some peaceful, some appreciative, some fearful, some outright absurd. But I wasn't motivated to write about any of it.

I wasn't especially motivated to think about any of it really, at least not meaningfully. When I spoke to my boyfriend by phone each evening, it was more about my curiousity about his dietary habits in my absence than about what it felt like to watch an old man drool and defecate on the floor. I rarely emailed with my mentor -- and when I did, it wasn't about what it was like to watch a room full of completely hopeless, barely functioning adults throw Dominoes at one another. When I fell asleep at night, I wasn't thinking about how helpless and incompetent I 'ought to' have felt about my inability to contribute anything to these people's lives. I wasn't thinking at all.

For all my talk of mindfulness, I was -- in a sense -- completely mindless.

And the days sort-of felt so. Though I attempted to approach this rotation with a specific set of structured goals, and though I fed off the positive energy of my attendings (who framed, for themselves, their role as more palliative than anything else), the day sort of ticked along according to a script. It was much like the rote, cursory scripts that many of the patients regurgitated with each interaction. There was very little connectedness; very little left with which to connect.

I had a good grasp for what was going on around me. My 3.5 years working in a psychiatric consulting practice before medical school left me with vague recollections of terms and drugs and phenomena --- things to which I've given absolutely no thought in the 4 years since I moved on from that particular job, but that surprisingly proved to be quite retrievable. I had the data points in mind, and tasked myself with learning how to manipulate that data into a usable form -- particularly as I imagined it playing out in primary care. It was a good approach, I'd say.

Today, I had my evaluation meeting with my attending. Turns out, he'd picked up on what I'd been doing. We talked about it. It was good. But when it came time to give me feedback on points for improvement, he said something I'd never expected:

"You need to give yourself permission to feel confident."

I've used the 'give yourself permission' construct quite a bit, for myself and for the athletes I coach, in a variety of contexts: permission to feel anxious, permission to feel uncomfortable, permission to feel (and outright be) awkward, permission to feel something. I've talked about the role of confidence in dictating my interactions with the world. But I've never combined them. It's always been about 'giving myself permission' to feel however I'm feeling, as a vehicle to reach confidence. There's a subtle difference.

"You know a lot," my attending said. "You know more than many of your peers. I see that. You need to decide to step up and use it."

I heard what he was saying. I'm exceptionally timid. I try to stay out of the way, kinda dance around in the questions I ask, never ever contribute my opinions. I'm obsessed with not looking stupid. I don't "take control" of the management of the patients I follow, because I feel like it's not my job. And very specifically, that's what feels most awkward about being a clerk. I don't get to practice making decisions. I didn't think it was my place. In a lot of cases, it's not going to be.

I asked him for some strategies for framing this issue, as I recognized it as stemming from a greater issue - a reinvention project that will go on indefinitely, I expect.

"Do it for your patients. Speak up not for yourself, not to impress your supervisor. But do it for your patients," he said. "Don't be afraid to be wrong. Just do it. Do it for them."

I'll try.