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Special Report

The Voices in My Head (and Yours Too)

Gray, Sara MD

doi: 10.1097/01.EEM.0000574772.38087.a6
Special Report



Part of my job is working in the ICU, and sometimes I connect with my patients. One week I had a patient I saw every day, we talked, and she touched my heart. She had been in the unit on a ventilator because of pneumonia, but she was getting much better.

One day, she was actually ready to be extubated. We extubated her, a normal everyday event. Her bed was right across from the nurse's station, and a few minutes later, I was standing there chatting when I heard her stridor. First a little bit and then a lot, that stridor. My planned extubation was not going well, but this was still a normal everyday event, and we prepared to reintubate her.

We laid her down flat, and she immediately obstructed completely. Within a few seconds, her Sat went to zero, and a few seconds later, we lost her pulse. She had a PEA arrest, and we started CPR.

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Critical and Sarcastic

If this were your case, how would you feel? What would your inner voice say to you right then? Can you hear your inner voice?

Life generally gives us lots of opportunities to practice this. Have you ever dropped your phone and cracked it? What did you say to yourself when that happened? It sometimes takes a little practice. At that moment in that resuscitation, I was trying to do CPR, optimize my team, and get an airway, but the voice in my head was calling me a stupid idiot and all sorts of worse things.

My inner voice is critical and judgmental and sarcastic.

I used to think it didn't matter. Nobody else could hear it; it's only inside my head. I used to think it didn't matter to high-level medical performance or to my resuscitation skills. Then I started looking at the evidence. It turns out your inner voice matters when you're trying to manage a complicated situation. It can lower your confidence, increase your anxiety, and raise your heart rate. Most importantly, it uses valuable cognitive processing power that would be better spent on the airway. I have this soundtrack in my head constantly. We all do. It can be very critical. How can we change that?

It is possible: You can train your inner dialogue. Elite athletes train on this, and I think we need it as much as they do. We can train on this by practicing self-compassion. The concept of self-compassion means talking to yourself the same way you would talk to your best friend using the same tone and language you would use with a close friend.

Self-compassion has been shown in the literature to reduce your heart rate, sympathetic surges, and stress-induced immune responses. In practical terms, this means your hands will shake less when you're trying to feed the wire on a tricky central line. This can help our bedside performance. I've realized that when you're good at your job, it's actually not easy to take it to the next level. You need to look for changes, sometimes quite subtle ones, to help you improve. Excellent bedside resuscitation isn't just about medical knowledge and technical skills. It's also about serious psychological skills.

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A Horrible Page

So there I was in my ICU, and we did a cycle of CPR and put an LMA in to buy us some time. She started to oxygenate, and we got her pulse back, but I could still hear stridor through the LMA. We knew her airway was difficult. I asked for a second doctor to be paged to come give me a hand, but my secretary was new, and he was terrified by this scene unfolding right in front of his desk. Instead of quietly paging my friend, he put out an overhead page to the entire huge academic trauma center.

The page went out: “Anyone with any airway skills, report to ICU immediately.” I heard that page, and a little part of me died inside and never recovered. I felt ashamed. We in medicine have been conditioned to view calling for help as an act of weakness, and I had just called for help in the most public way possible. Now my inner voice was even louder. It reduced my bandwidth even more.

These are the cases that hurt us, that lead us toward burnout, and we all need to care about that because we are all at risk, especially when you work in a profession where tiny mistakes can have life-or-death consequences. We all make mistakes. This is normal; we are all human. But we don't talk about them. We keep our tragedies and our failures hidden, so we can look perfect on the surface. We look happy on social media, but we feel terrible about ourselves inside.

The trouble is we start to feel shame and isolation when we stay silent. After years of this, it can lead us toward burnout, depression, addiction, and suicide. Suicide for me is the final common pathway. I have two close friends who died by suicide. I still miss them every day. They could never talk about their fears and anxieties, and they were overwhelmed. That's the price of our culture of silence.

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Gossiping and Judging

I'm not the only person whose life has been touched by this. Shame and isolation and loss are our hidden epidemic. We need to train to reverse this because it affects us all. I was there in my unit, and about 50 doctors came racing in: my boss, the chief of anesthesia, the chair of the ICU, half of the trauma team, every intensivist I knew. They all came jamming in, and they were looking at the case and judging my medical care. Some stayed to help me, but there were so many people that a whole bunch of them just stood at the nurse's station to watch and gossip and judge. I felt overwhelmingly intimidated. My ability to stay kind to myself was getting worse and worse.

It turns out that self-compassion is not just a light switch that you turn on. This is something you have to practice. Then you screw it up, and you try again a different way. This is work that takes years. It turns out that self-compassion for me is much harder than any other critical resuscitation skill. Resuscitative hysterotomy is easier than self-compassion.

If you're not sure how you're doing with this, go to this marvelous website,, an amazing site on self-compassion by psychologist Kristin Neff, PhD, from the University of Texas at Austin. The site has a quiz where you can see how self-compassionate you are. Take it and then retest yourself in six months or a year to see where you are. Another great experiment is to test yourself a few days before your vacation and then again the day after. When I do this, I see a huge and frankly terrifying change in my scores. We get compassion fatigue, and we need to learn how to replenish our reserves.

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A Failure Friend

So I was in my unit, and even with all of that help, we still couldn't get her airway. She ended up going to the operating room for a primary trach by the ENT surgeon. Someone else saved the airway on my case, on my patient. I felt terrible, but it wasn't only me, my team felt terrible. My nurses, my RTs, my fellows had just taken a hit. I needed to figure out what to say to my team as we debriefed, what to say to help them recover. Whenever I'm not sure what to say, I think about what I would say to my close friends, what tone I would use. These cases are difficult to talk about, but it becomes a little easier when you start practicing self-compassion.

My favorite construct around recovery is that you should find yourself a failure friend. This is your go-to person to talk to when you've screwed up. Choose someone nice, someone capable of empathy, someone who understands your context. I have one failure friend for the emergency department, one for the ICU, and three for parenting. This is the person you go to and say, “I had this case last week, and it's bugging me.”

To be clear, this is not M&M rounds. You don't need to tell them all the medical details. You have to do something a little harder. You have to tell them how you feel. Tell them when you feel like quitting, when you feel like drinking. If you've chosen wisely, they will lean in and say, “I know how you feel because I've been there too, and we will work through it together.” That's where we start to support each other because we have all been there. Everybody has had catastrophes.

How do we get better at self-compassion? You have to practice, but there are only two steps. First, listen to your inner dialogue. If you can't hear it, try dropping your phone or spilling coffee on yourself, and you'll generally hear it louder. Secondly, change your language and tone to be more compassionate, and then practice that. Keep practicing until self-compassion is your habit. I bet you already do this every day for your patients and families. You can choose to do this for yourself. You deserve it just as much as they do.

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Back to the unit: My patient came back from the OR. That morning she had been ready to be extubated and leave the ICU, and now she was back. She was on a ventilator. She was post-arrest, and she had a surgical airway in her neck. She was also wide awake and looking for answers. I went to talk to her and her family to explain and to apologize and to give them the kindness and compassion they needed to cope. I was so much more able to give them the compassion they needed than I was to give it to myself.

Maybe some of you are already pros at this—I hope you are excellent at this. Turn your skills outward: Teach your patients about self-compassion. This has been shown to improve medication adherence and self-care in chronically ill patients. Teach this to your teams and your students or, even better, role model it. Show them how you recover from a difficult case and the skills they can adopt. Teach your children to be kind to themselves when they make a mistake, so they grow up to be more resilient than we are. Let's make sure the next generation's burnout rate is lower than ours.

Self-compassion is a skill you can use every day. It helps your bedside performance, reduces burnout, and helps you recover faster. I went back to my ICU the next day, and the RT came up to me—the same RT from the previous day—and she said the man in the next bed was ready to be extubated. He had a known difficult airway, but he was ready. The question was, though, was I ready? Was my team ready? Had I recovered enough to perform at a high level? These cases make us afraid, but self-compassion helps us walk through that fear with more courage and more grace.

There are three easy things you can start today. Start listening to your inner dialogue, paying attention to what you say to yourself. Then start practicing better self-talk, learn phrases or words that work for you, and spread those to your teams and families. Finally, use those skills and empathy to take care of our community; be someone else's failure friend and respond to them with compassion rather than judgment or gossip. Self-compassion can make your work, your performance, and your life better—for free—starting right now.

I hear voices in my head. So do you. But maybe if we all start paying attention, we can move to a better place.

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Dr. Grayis an emergency physician and a critical care intensivist at St. Michael's Hospital in Toronto; an associate professor of medicine at the University of Toronto; the vice chair of the Canadian Association of Emergency Physicians Wellness Committee; and a professional coach for health care professionals. Read her blog at, and follow her on Twitter @EmICUCanada. This article was first presented as a talk at DAS SMACC. Find a video, podcast, and slides from her presentation at

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