Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] The wellness industry saturates our cultural consciousness with juice cleanses, organic skincare, spa retreats and more flooding our social media feeds. But what does this plethora of dazzling and expensive lifestyle products all amount to? Not much, argues Dr. Pooja Lakshmin, a psychiatrist who specializes in women's mental health and a clinical assistant professor at George Washington University School of Medicine. As she writes, "our understanding of self-care and wellness is incomplete at best and manipulative at worst. We cannot meditate our way out of a 40 hour workweek without child care. These wellness products keep us looking outward, comparing ourselves with others or striving for perfection." She details her ideas for achieving true wellness in her recently released book, Real Self-care. In this episode, Dr. Lakshmin joins us to discuss how she overcame her own struggles working in medicine and details, practical strategies for real self-care, which in her words, "isn't a thing to do or buy, but a way to be." Pooja, thank you so much for joining us and welcome to the show.
Pooja Lakshmin: [00:02:13] It's great to be here. Thanks for having me.
Henry Bair: [00:02:15] Can you tell us what first drew you to a medical career?
Pooja Lakshmin: [00:02:19] This is a question that sort of gets deep into, I think, all of the different ways in which, you know, family of origin and identity and immigration come into play. So my my parents are immigrants from India. My father's a physician. He's an anesthesiologist. He's retired now. So I'm South-Asian American. And it was sort of always assumed that I would become a doctor because I'm Indian, you know, And I think especially in the Asian immigrant community, in that first generation community, you know, sort of the model minority, sort of like, oh, well, you're going to be a doctor or you're going to be an engineer or maybe gasp, you'll be a lawyer. Right? So and I was I was good at school. You know, I was like a valedictorian in my high school. I got into Penn for undergrad and somehow excelled in like, orgo and all the classes. And it was funny. So at Penn, I was a double major. I was biological basis of behavior and women's studies. And I remember once not to throw my parents under the bus, but I guess I will throw them under the bus. And if you read my book, you'll see hear about that more. But I remember having a conversation with my mom at one point where I was like, you know, I really want to be a woman studies professor.
Pooja Lakshmin: [00:03:35] Like, that's really what I want to do. And she was just like, "But Pooja, how could you do that?" You know, Like it was just like outside the realm of possibility, you know? And I understand that now after like, you know, I'm 39, years and years of therapy. I understand that, you know, my parents came to America and they wanted their daughter to have a career that was, you know, secure and had a certain level of prestige and like, you know, always provided for me. Right? So it's coming from a good place. But, you know, long story, long. I went to Jefferson for medical school and my first rotation was actually OB-GYN, and I thought that I was going to do OB because I wanted to do women. I wanted to work with women, but I hated being in the O.R., despite the fact that my father is an anesthesiologist. And I did psychiatry last. And I knew within the first week of my psych rotation that I just knew that psych was for me. I was like, these people are so talking about the attendings and the residents. It's like, these people are so weird and they are my weird people.
Pooja Lakshmin: [00:04:36] Like these are my people, you know? And I just loved it. It just it just totally fit me. And I remember being worried of, like, what were my parents going to say? What were other people going to say? Because, you know, in medicine, psychiatry is still considered a little bit of sort of like the black sheep, like, you know, why would you go to med school and spend all this time and money if you were just going to become a psychiatrist and sit on a couch and talk to people? But yeah, that was the right move for me. So it's kind of what brought me here. And then and then my journey from there has just always been I was really conflicted about medicine because of all the ways in which it has let me down and has let my patients down and has in the way that medicine treats doctors right, the way that medicine treats its people. So. So I left medicine for a little while and came back. And so it's sort of like an ongoing journey for me of figuring out how to be a psychiatrist, how to be a physician in the way that is aligned with my own values.
Henry Bair: [00:05:34] What did you do in the in the period when you left medicine?
Pooja Lakshmin: [00:05:38] Yeah. So I talk about this in real self care in the introduction. It was a very messy period in my life, so I had gone straight from undergrad at Penn, Med School at Jeff. I matched at Stanford for my psychiatry residency, got married, moved across the country, and it was my PGY two year of psych residency. And I was not only completely burnt out myself because I'd never taken a break, but I was also just really disillusioned. I was really disillusioned with how little power we actually had as physicians in that, you know, somebody comes into the E.R. and they're unhoused, and the only thing that we can really offer them is Zoloft or therapy. I mean, we can't even really offer them therapy, right? Because therapy is too expensive for most people. But what this person actually needs is housing. Or, you know, the woman who loses her job because she doesn't have child care. Right. Like Zoloft isn't going to fix that. And I just felt really, really angry with the fact that I didn't have the resources or the tools to fix this incredibly broken system. And then in my own life, I was just sort of questioning all the things that I thought were- that I had previously sort of held up as gospel. So whether it was like going to the prestigious schools or getting married or doing all the right stuff, sort of climbing the path. And so I ended up leaving my marriage. I moved into a commune in San Francisco that practiced orgasmic meditation. I dropped out of Stanford, and to be fair, I was totally underperforming in my residency because I was burnt out and depressed and questioning everything.
Pooja Lakshmin: [00:07:27] So ultimately I left and spent two years with this group and studied female orgasm at a neuroscience lab at Rutgers that puts people in fMRI machines and looks at the brain when they're having orgasms. And by the end of that journey, you know, that was two years. And I realized that the spiritual world or the alternative medicine world has just as many hypocrisies and contradictions as allopathic medicine. And you really can't just, you know, like you'll never find the solution outside of yourself. Like no wellness practice, no guru. There is no magic panacea, right? And so ultimately, I was really heartbroken about leaving this group. But I left the group and, you know, spent my 30th birthday completely depressed, nearly suicidal in my childhood bedroom, turning 30 and kind of facing coming back to medicine and reapplying. And I was really fortunate to get a third year spot at GW on the East Coast. And ultimately that ended up being the right fit for me. But also I think in leaving what I later realized that this was actually a cult, you know, and other media reports came out about how dark the story was in this group. But leaving the group was actually what helped me understand that ultimately, like, you have to make your own path. And that was something that I really needed because, you know, medicine is such a hierarchical system too, you know, and you spend so long thinking, okay, well, I'll be okay as long as I get through. And once I get through internship, then I'll be happy. Once I get through residency, then I'll be happy.
Pooja Lakshmin: [00:09:05] Once I get through fellowship, then I'll be happy, ad nauseum. Right? Like when? When do you actually when do you actually get to be happy? And I realized like, oh, I have to do that for myself, you know, I have to give that to myself. It's not going to be like a yoga practice. It's not going to be a meditation. It's it's actually in making these hard decisions and figuring out what actually fulfills me. And so when I came back to residency, I had learned, you know, how to set boundaries. I had learned that I have to make hard choices. So ultimately, I graduated in 2016. And. Came on the faculty at GW. We have a women's mental health clinic called Five Trimesters, and I specialize in perinatal psychiatry. And now I am kind of building this very multi-hyphenate career where I'm still on the clinical faculty. I supervise Our residents, I have a private practice where I do women's mental health. I'm an author, I have my first book is Real Self Care, which is just coming out. And I'm the founder and CEO of Gemma, along with two other psychiatrists, Dr. Kali Cyrus and Dr. Lucy Hutner. And Gemma is a women's mental health community focused on impact and equity. So I'm kind of charting my own path. And all of that I think came from. Understanding that like real fulfillment, real self care. All of this is is something that you have to make for yourself. It's not you can't just follow someone else's path. You can't just go to Target and buy, you know, scented candles off of the shelf and then expect everything to be better.
Henry Bair: [00:10:42] Yeah, there is so much there for us to unpack. And I'm grateful that you are open and honest in sharing your own difficult experiences and your way back, of course. So you've alluded to this briefly about your your explorations and then subsequent disillusionment with, I guess, wellness, the wellness industry, which is huge these days. It's quite it's it's been mainstreamed by, you know, you even have documentaries about these wellness solutions on Netflix. So can you characterize for us what the state of that industry is like and what are some of the the biggest myths and misconceptions around that wellness industry?
Pooja Lakshmin: [00:11:26] Yeah. So the first question of the state of the industry is that it's ginormous. Like multiple trillions of dollars a year are spent on wellness products and it's only growing right exponentially. When I was researching Real Self-Care, I found this interesting statistic that apparently Google searches for self care peaked in the United States on the night of the 2016 election. So I think there is a connection between the way in which Americans in particular, how. You know, I think there's a connection between the loss of trust in public institutions, whether that is health care or whether that is government, whether that is church or religion and the proliferation of wellness as kind of a solution. I would also say as a psychiatrist, I think that we can also tie it back to the fact that mental health care, I mean, health care in general, but really also mental health services are completely broken in America. You know, it's so much easier if you're somebody who struggles with anxiety. It's so much easier to, you know, click "buy" on an Instagram ad for some vitamin that says it's going to cure your anxiety that comes in, you know, pretty beige branding and will be delivered to your doorstep in 24 hours. Then to do the hard work of having to call your insurance company and fight with them to try and get your therapy sessions covered. So when I think of wellness, I think that wellness is consumerism-oriented, right? Wellness is something in America that we have been taught: You buy something, you do something. It's always outside of you. And in Real Self Care I'm proposing that instead the solution is actually inside all of us. It's not something that you can buy.
Henry Bair: [00:13:28] Mm. What are the harms of conventional self-care? As you know, as we've been talking about, you know, with, with the wellness industry, I mean, a lot of people appear to be getting a lot out of it. So what's wrong with it?
Pooja Lakshmin: [00:13:42] I think there's sort of two lanes here. So I think there is a cohort of wellness products and services that are doing damage because they are in the way that they advertise themselves. They are appealing to folks who are quite vulnerable. So whether it's, you know, the pill that is not FDA approved and says that it's going to cure your anxiety or, you know, the the the little essential oil that says it's going to, you know. cure your depression. I think that group of wellness products can be really dangerous because somebody might read that advertising and falsely believe that taking this product is going to be the thing that treats their suicidal depression. Right. And then doesn't actually get therapy or take a medication that is FDA approved. So I would say, you know, that's the harm, right, of not seeking evidence based treatment, instead spending months or years chasing sort of these solutions that are not proven. And then I would say that there's another cohort of wellness products. And this is like where I would you know, this is where I'd categorize like the bath bombs and like the yoga classes and the retreats and the things like that where it's not as nefarious and there's less risk of harm, but it's more just like those are temporary solutions. Those are Band-Aids because you're overwhelmed, you're stressed. You're in my patient population. I work only with women and people who identify with women. So I take care of a lot of moms. You know, moms don't have time for anything. Like, you know, the data is that American moms have like 30 minutes of discretionary time per day, which I think that's probably even like seems like a little bit of an overestimation. So it's like you're just turning to an escape, right, with the bubble bath or the yoga class. And it's not that that is wrong or harmful. It's just it's not going to fix the root of the problem.
Henry Bair: [00:15:52] I think here's a good place for us to delve into what actually addresses the root of the problem. This is, of course, the basis of your book, Real Self Care. What is real self care?
Pooja Lakshmin: [00:16:04] Yeah. So real self-care is a decision making process. So real self-care is not something to buy or to do. It's actually a way to be. It's the way that you make choices about how you spend your time, how you give your attention, how you spend your energy. It's a verb. It's not a noun. So I'll give you an example. From my practice. That's really common. You know, like the woman who comes in and says that she finally made time in her day to get a massage and she went to get the massage. And then she spent the entire hour on the massage table just worried about her to do lists and feeling like because she had taken that hour long break, now she had to catch up and, you know, do all the stuff that she didn't get to. And the reason that that whole situation happens is because she is using the massage as a tool and a coping mechanism. But she hasn't done the work, the internal work to actually get clear on the principles of real self care.
Pooja Lakshmin: [00:17:11] So in the book, in real self care, I distilled this whole internal process down to four different principles. The first is learning to set boundaries and deal with guilt. The second is developing self-compassion in the way that you talk to yourself. The third is understanding your values because everybody has a different set of values and so every person's self care is going to look different. And I've created a specific tool called the Real Self-Care Compass, which helps you get clear on what your specific values are. And then the fourth principle is that this is actually power and we need to conceptualize real self-care as power. So turning back to the the iconic Audre Lorde who talked about self-care being self-preservation, ultimately the problems don't lie within individuals. The problem is actually in our oppressive systems, whether that is a toxic medical culture, whether that is capitalism, whether that is white supremacy, right? The confluence of all of these structural ailments all come together. And the individual, the worker is the one who is harmed. Real self-care in itself is a process, is the process of taking back your power and protecting yourself. And then the next step is if you are somebody that does have some privilege, if you do have resources, putting that energy and that power back into vulnerable communities.
Henry Bair: [00:18:47] That's great. Thank you for giving us a broad overview of that and I'd love to drill down on those four principles. So the first one you mentioned was was moving past guilt.
Pooja Lakshmin: [00:18:56] Yeah, Setting boundaries and moving past guilt. Yes. Yep. Yes.
Henry Bair: [00:18:59] So setting, setting boundaries. So can you tell us more about what that actually looks like? Yeah.
Pooja Lakshmin: [00:19:04] And setting boundaries and moving past guilt is the first principle of real self-care. Because unless you learn this skill to start with, none of the rest of the work is possible. So I'll give you an example. When I first started on the clinical faculty at George Washington University, this was way back in 2016. My advisor, my mentor took me out for lunch and she gave me a piece of advice. She said, "Pooja, you don't need to answer your phone." And I was like, What? That doesn't make any sense, right? Because I just graduated residency and. Right. We had we used to have these things called beepers. I don't know if residents still have those anymore. Right. But you had you got paid and you were like it was like a PTSD response, right? You like you answer immediately. And she was like, "no, Pooja, you don't have to answer your phone. Just let it go to voicemail and then listen to what the person wants and then you can respond." And that was like a little bit of an aha moment for me because I realized, Oh, like your boundary is in the pause. Like you can take the time to hear the other person and then you can stop. And then you decide whether you say yes, whether you say no or whether you negotiate. And so in that context, for your listeners, many of whom I'm assuming are in the medical community, right, it's like it could be the front desk asking me to sign a bunch of papers, which I in that case could just say, Hey, I'll finish that when I'm on my way out. Or it could be a patient calling to say that she is out of her stimulant. Right. And if she doesn't get the next refill, she's going to be really struggling. But then I can decide I'm going to call her back and put in the order. Right? So it's like it actually frees up my attention and my ability to be in control of how I spend my energy. So that that's what I mean when I say setting a boundary. And it really is in the pause.
Tyler Johnson: [00:20:59] Yeah, you know, I resonate with that so much. And it it took me a long time after I finished my training, right? So I did medical school like everybody, then residency and then fellowship. And it was a long time after I finished my training that I recognized that the, the meat of medical training, in effect, is boundary erasure, right? Like there just is no boundary at all and it is drilled into you over and over and over and over and over again. And not only is there no boundary, but you can't even set boundaries to respond to the people who are already violating your boundaries. Right? Like if you're getting paged and you're responding to this page and then somebody pages you somewhere else and you don't respond to that page because you're taking 15 minutes responding to the first page, then the second person gets mad at you for not responding quickly enough when of course you're human and can't violate the laws of physics. Right? And like things like wanting to go to, I don't know, things that are personally important or whatever are just not even like that's not even on the radar, right? I mean, it's not even like in the discussion. And so I think that you're right that I mean, and I you know, I think there's a little bit of a reckoning going on right now about exactly what medical training is supposed to look like because people are finally starting to ask whether that's actually a good idea to erase all of your boundaries for a decade while you're in training. But even when you get to be doctors, we become so I mean, like you're finished with all of your training. You're so acculturated to not having boundaries by that time that it has to be a very conscious act, just like you said, to be like, Oh. Oh, okay. So I'm going to unlearn the reflex that I learned, right? So that it's not just like, Hey, you medical trainee, do this thing. Okay? Sure, fine. Right. Like it's this very it requires a very conscious act.
Pooja Lakshmin: [00:22:52] I love that you brought that up, Tyler, because I completely agree 100%. And I think that it's cultural, right? Medicine is a very specific type of culture and trading. And we know a lot of it comes from sort of like the army hierarchical mentality to in 2018, I wrote a piece for Doximity called We Don't Need self Care, We Need Boundaries. And it was written for a medical population. And it was sort of what put my writing on the map and led to me writing for the New York Times. But it was sort of like, yeah, like we don't need a resilience training. We don't need like a mindfulness session. Like we need to learn to actually set boundaries. And the hard thing with that is that that means you have to grapple with as a physician that you're not a superhero, that you're not superhuman, you are just a human like everybody else. And I think that there is in real self care, I talk about like this martyr mode, right? I think the ego hit that we get when we are the one to save the day. It's really hard to let that go, you know? But I think that we need to do a better job early on in training of recognizing the fact that it's harmful. And I, you know, talking about this earlier, like that's what led to my own burnout and leaving medicine and having to come back and understand like, no, I can only be in this system if I do it in my own way. And that's going to also mean that some people are not going to like me and be mad at me. And I think we have to learn to be okay with that.
Tyler Johnson: [00:24:25] Well, and I think, too, that it's it becomes even more deeply embedded. So I you know, for my own formation or the formation of my own thinking about these questions, I feel like one of the most formative things that I have ever read is this New York Times editorial that was published about 3 or 4 years ago that the title I won't get verbatim, but it's pretty close that, like the business of health care is built on the exploitation of health care workers. And it really is this sort of vicious yin and yang. Right? Because on the one hand, you have the business side of medicine that is there to maximize profit and therefore is trying always to maximize efficiency because that's how they maximize the profit. But their motive is profit driven, even not for profit hospitals, their motive is still profit driven. Right. But then on the other hand, you have medical professionals who generally go into medicine for altruistic reasons. Not to say that everyone's perfectly altruistic, but there is this sort of, you know, you almost want to be a hero or a martyr because that's sort of why you went into it, right? And so when you have the business side squeezing and squeezing and squeezing tighter and tighter and tighter, and you have the the health care altruistic side saying, okay, yeah, I can do that. I can do that. I can do that. I can do that. I can do that. Right. Then at some point the individuals and then the system just reaches a breaking point because you get squeezed past the point of no return and you don't even recognize it anymore. Right? Because you've just become numb to like because in your mind you experience that as a moral act when in fact, at some point you're just being taken advantage of.
Pooja Lakshmin: [00:26:04] Yes. And I think that that what I've learned over the years is that same whether we call it abuse, whether we call it toxicity, you know, I think it extends across multiple industries. It's not just medicine. And one of the things that I often write about is the way that this overlaps with motherhood and parenting in America that we saw sort of especially during the pandemic. You know, I wrote a piece that was called "This Isn't Burnout. This is Betrayal" in the way that sort of all of our systems just completely let parents and mothers sort of fend for themselves when it came to child care and school during the pandemic. I have an eight month old now, So, you know, now I even though previously I really understood the importance of childcare from, you know, being a perinatal psychiatrist now, I very much am like living it. And my son has been like sick this whole week. And so it's like. Again, it's like in these toxic systems, whether it's health care, whatever industry it is, the way they get you is putting the onus of responsibility on the individual right, when in fact it should be the collective system that is coming together to support the workers. And I don't know. I think in medicine, like I'm kind of a not a kind of a pessimist. I am a pessimist. Like the only way that I've been able to make it work for me is to lead. So I'm a clinical faculty at GW, which means voluntary. So I supervise residents. I have a very circumscribed role for our five Trimesters clinic, and then I have a private practice and I have my company, Gemma, and I write. So I'm like essentially, I'm like freelance. I feel like that's the only way that I've been able to protect my mental health. And I don't know, like, I honestly, I don't know if it's possible to change the medical system. Like the only thing that has worked for me is to essentially like leave and only pick and choose the ways that I interact. I don't know what you guys think, but that's that's my pessimistic view.
Tyler Johnson: [00:28:05] Back 15 years ago, when the ACGME put in their first iteration of work hour rules, which let's give a little bit of perspective, right? For people who may not be familiar, these work hour, quote unquote restrictions were that you could only work 80 hours a week and you could only work a 30 hour shift and you could only write like an average of 80 hours a week. Right. Which meant sometimes it was 90, really 100 and whatever, whatever. But when they put these work hour restrictions in to program directors from two of the most prominent internal medicine training programs in the country wrote a letter that was published in the New England Journal that said We cannot train doctors under these restrictive conditions. And if this is not changed, we will quit. It is like the people who are putting the people in Stockholm Syndrome writing a letter to brag about the fact that they're causing Stockholm Syndrome. Like it's so bizarre. Right. But the fact that they would do that and publish it in like the most recognizable medical publication in the world is just so...I don't even know the right adjective. Right. But I mean, it is just it really strains belief. Like if you didn't actually see it, you would have a hard time believing that it was actually there.
Pooja Lakshmin: [00:29:22] Yeah. Well, it's like the system is just completely rigged. And the other thing I'll say on that is that. If you're somebody who has any level of privilege, whether it's privilege based on the color of your skin or your financial resources or not having any type of disability, like it's so much easier to protect yourself. But it's the medical trainees and the med students who are like the first generation doctor in the family who are graduating with like hundreds and hundreds of thousands of dollars of med student loans and then enter into the system and you're just like, oh my gosh, this is terrible. You know, I'm depressed, but I don't have any alternative because I have all these student loans on my back and I don't know how to interact in the world because I've spent my entire life up until this point training to be a doctor. And I'm supposed to be happy, right, that I achieved this. So I don't know. It's funny, you know, I'm Indian. And so, like, of course, all my parents friends used to like, send their kids to talk to me about because everybody was always trying to get into those like six year med programs. And whenever anybody would call me, I'd be like, No, no, like go to four years of college. Like, why would you want to cut that short? And so, like, then, of course, like the aunties and uncles stopped like sending their kids to talk to me. But I don't know. I don't I don't think that I would encourage my son to become a doctor. Like I just I don't think it's not worth it.
Henry Bair: [00:30:52] It's interesting that you'd say that. So I'm a medical student at Stanford University, and my understanding is that Stanford doesn't have a particularly robust pre-med advising program for its undergraduate students. At least that's what the undergraduates tell me. So a lot of pre-med college students end up looking to medical students for mentorship. And for whatever reason, I happen to be the recipient of many of those requests at any given time. I mentor between 10 and 15 pre-med students, and I really enjoy it. But when I think about it, a surprising number of people I advise between a quarter and a third have been dissuaded from going to medical school as a result of our conversations. And it's not me saying that this is a terrible career and it's not worth it. Rather, it's me laying out what the path ahead actually looks like because many pre-med students have little understanding of what residency or fellowship is, they don't realize the incredible financial costs of medical training or the 80 plus hour workweeks, or that it'll be 7 to 10 years after college or even longer before they finish training. When I laid out for them, many of them realized medicine might not be the best fit for their values, career goals and skills.
Henry Bair: [00:32:08] Transitioning a little bit, I'd like to talk about the next principle of yours. You mentioned that after setting boundaries, you might feel some guilt. You might still struggle with that martyr mode. And here's where you talk about self-compassion. So what is self-compassion and what does that look like?
Pooja Lakshmin: [00:32:25] Yeah, so I'll admit that even though I'm a psychiatrist and have been through at this point, probably eight years of my own psychoanalysis on the couch with my analyst, self self-compassion has always still felt like very sort of woo woo. And eye-rolly to me, like, I just always thought like, oh, it's just you're going easy on yourself, you know, Like, this is just not for me. But the definition of self-compassion that I use in real self care is actually coming from Kristin Neff, who is a psychologist and probably the foremost researcher of self-compassion. And it's not mantras or affirmations. It's actually looking at how you talk to yourself and the conversation that you're having with yourself. So it's based on a concept called psychological flexibility, which comes from acceptance and commitment therapy. So it's more like, you know, if you find yourself saying, gosh, you know, Pooja, like, you know, like you yelled at your son, like you're a horrible mom. Here, self compassion. We say, Well, that's interesting. Like what? What makes you think you're a horrible mom? Like, it's kind of like being curious at those inner critical thoughts, which then opens up a space for those thoughts to not have to be the capital T truth, because really with what we're doing with self-compassion is just trying to open up the space for there to be other narratives, right? And I think when we're talking about like medicine, the constant internal monologue is like, I'm not doing enough, I'm not getting enough done. I'm a bad parent. I'm a bad doctor. Right. Because nobody ever has enough time. And instead kind of questioning it and saying, well, do I have enough support? Like maybe one of the reasons that all of this is so hard is because I'm trying to actually do too much. And maybe this is actually physically impossible, right? As opposed to just constantly berating yourself.
Tyler Johnson: [00:34:20] Since I learned about the idea of moral injury and started looking for it in medicine, which is kind of like the evil twin of or the like, the lack of self-compassion, right? I feel like moral injury is just all over the place, right? So if you think about an intern to the point that I was making earlier, it is often the case that interns are being simultaneously asked to do multiple very important things, which, even though it may not technically be true, often feel like they are that life and limb depend on them and they're being asked to do all of them simultaneously with everybody who's waiting for their thing to be done, thinking that it's just as important and that it should have just as much precedence. And the poor intern is left, you know, paralyzed because you can't do ten things at the same time. Right. And so no matter what you do, even if you manage to do two of them in this allotted time for one of them, then you're still left with the moral injury of not having done the other eight and feeling guilty that you didn't get to the other eight that were physically impossible to do in the first place. Right. And then the other thing that that makes me think of along the same lines is that in our medical training, it is unavoidable. If you are taking care of sick patients, that you will have patients who have quote unquote bad outcomes. It just will happen, right? If you're a psychiatrist, you will have people commit suicide.
Tyler Johnson: [00:35:41] If you are an internist, you will have people who die from heart failure. If you are an oncologist, you will have people die from cancer. And over time you develop enough of a like a wide enough view to say, oh, this is a thing that happens to sick people because bodies die. But when you're the intern and it's the middle of the night and the patient who you thought was getting better suddenly gets really sick and dies. In my experience anyway, it is almost impossible not to feel like it's your fault. And in that moment, what in this very clinical, detached conversation we can refer to as a lack of self compassion feels like an indictment for murder or manslaughter or something, right? Like you're alone in some call room. There's nobody there to give you perspective. And you think, Oh my gosh, this person died and it's my fault. Or, you know, whatever. They went into kidney failure and it's my fault or whatever the thing is. Right. And I think that that sort of. Delay, right? Like putting a space in the synapse so that you don't go right from bad outcome to it's my fault and I'm a terrible person and a terrible doctor is hugely important. And yet it's something that we I mean, nobody trains us about that, right? At least I certainly never had any training about that. Right. It's a conversation that goes almost completely on hand.
Pooja Lakshmin: [00:37:01] Yeah, I love that you make this connection. It makes me think of two things. One is that, like, essentially what we're talking about is making space and holding space, right? Holding space for feelings, holding space for grief, holding space for ambivalence. And one of my partners at Jemma, Lucy Hutner, Doctor Lucy Hutner, she's also a psychiatrist. She wrote a piece for our Substack, Therapy Takeaway, which is our email newsletter about holding space last week. And it centered actually on how in her medical training, it was never something that there was room for because again, like we were talking about earlier, all of medical training focuses on productivity, right as the pinnacle of the outcome. The other thing I was thinking about is just the overlap, you know, because my field is, is women's mental health and motherhood is just like the overlap of medical training and parenting and how like in the same way, all the rules are contradictory, right? And when you go down one path, you feel guilty and bad because you're not doing something else because it's, you know, humanly impossible to do all the things right. And how we then internalize that as parents, as mothers, as anyone who's a caregiver. Right. And because ultimately medicine is caregiving. Like the art of medicine itself is being a caregiver, which is something that is hugely labor intensive and hugely emotionally taxing. But yet the industry of it is all about productivity. So there's always like this values misalignment.
Henry Bair: [00:38:44] Yeah. Which actually values the values misalignment. So that's, that's great because I think this principle of yours is so intimately tied to the next one, which is actually getting to know what your values are, getting to know what your beliefs and your goals and your, your desires, what they are, right? And so your third principle is, is getting to know yourself, your true self and the tool that you just you created to help guide that conversation with yourself is the self care compass. So can you tell us more about that?
Pooja Lakshmin: [00:39:14] Yeah. So the real self care compass is all about understanding your internal values and values are different than goals, right? Values are qualities that you can embody and a goal is something tangible. So a goal might be, you know, I want to get into medical school or I want to get into a certain residency, but a value is like, okay, but how do I want to feel when I am striving towards that goal? And I will say, for any of the premed people out there, I know that that question is like, you know, you're just kind of like, what? No, my goal is just my goal. I just I need to get into medical school. I don't care what I need to do to get there. So this is this is sort of asking you to say no. Like, do you want to be somebody who, like, what's most important to you is like courage, most important to you because you're the first person in your family who's embarking on this. Is curiosity something that's really important to you? Do you love like finding out the answers? Is self-expression really important to you? Are you going into medicine because you really want to learn the stories of others and be able to get closer to your own story? Everybody has a different blueprint for their values. And so the compass is this tool that really centers the values and puts the goals Second.
Pooja Lakshmin: [00:40:30] And I think for medical folks in particular, that is so important because we just we're just so goal oriented like we're so goal oriented. And ultimately getting clear on your values is how you can then go on to starting to kind of build a life that fits more in line with your own well being. I will say one thing about this is that especially for doctors, I think it can be really scary to have these conversations with yourself because sometimes the answers that you get back are terrifying. You know, like the answers that you get back might be something like, I hate this job. You know, I want to quit. I want to run away. And I just want to sort of. Speak to that and say, just because you get back a scary answer doesn't mean you need to take action, right? Like this is just about having a different conversation with yourself and when you're in that state of burnout. There's never going to be one choice or one decision that makes it all better. Like recovery from burnout because of a toxic workplace is going to take hundreds of decisions. So you're just kind of like starting this conversation, but don't feel intimidated. Like you need to make some sort of big change just because you don't like the answers that are coming back.
Tyler Johnson: [00:41:50] I think, too, that there's a really important paradox embedded in that kind of self interrogation for doctors, which is that I think that. Medicine is viewed as a noble field, and because it's viewed as a noble field, I think it's kind of easy to think, well, part of the reason I'm going into medicine is because once I get there, I won't have to worry about the values part of it, right? Like if I was going into investment banking or if I was going into accounting or into being an attorney or something, then I would really have to worry about my moral compass. But if I'm going into medicine, I think that sometimes there's this kind of unspoken assumption that just by virtue of being a doctor, of course I'm going to be following my values because I'm going to be a doctor. So how could I be doing anything else? Right? But to your point, first off, there's many different ways to be a doctor, not all of which actually honor really much of any set of values. And secondly, it's well, there's three things. There's that. The second part is that, you know, your values, even if they're strong, may not necessarily align with what you end up doing in medicine or what your day job is. And then the third thing is you mentioned is that there's always going to be outside systems, whether you're an academic doctor, and it's all about getting tenure and being published or whether you're working at a private practice And it's all about seeing more patients and getting more RVUs, there are always going to be this these extraneous forces that are trying to divert you away from your values. Sometimes they're inimical to your values, or at least they're almost always agnostic to them. Right. And so all of that is just to say that I think it's important to reaffirm how vital this is to doctors, precisely because we sometimes think that, oh, like I'm a doctor, I don't really need to do that.
Pooja Lakshmin: [00:43:37] Yeah. And I think like part of that maybe going a layer deeper is like values are morally neutral. I think, Like there's sort of like this Good Samaritan kind of undertone to becoming a doctor. But operationally, your life looked very different depending on what type of doctor you are. But again, like there's so many different values that you can turn the volume up or down in doctoring. Like I'm just thinking of like, you know, the pediatrician who really values silliness, right? And you really love to bring that fun to the office with your patient. Or maybe it's like the surgeon who is value for you is like order, Right? And you, you're in the O.R. and you can be super meticulous and you get to just really, like, turn the volume up on that. So when I'm talking about values, it's less of, like, morally good or bad and more of just like these adjectives in your personality that get to the essence of you. So for me, it's like self-expression is something that is a value that's really important to me. Creativity is a value that's really important to me, which is why I've ended up, you know, why I have like five day jobs because I like to just always be doing a million things and creating and building, right? So it's like you can play with that and it doesn't have to be so serious. But I think getting to your point, Tyler, I do agree that. I think because medicine has like sort of like the quote unquote brand that it does, maybe people think that like, you can just check that box off and you don't have to think about it. I do agree with that.
Henry Bair: [00:45:09] So a lot of the the conversations we've been having are about what we can do. It's about getting to know who you are and your how you want to interact really with the system around you. But then you bring it to the fourth principle, which is then expanding that outwards, turning outwards and seeing how you can transform that real self care approach mentality into broader systemic change. Right? Which can seem a little bit abstract. So can you tell us what are the actual concrete steps to achieving that, to empowering yourself, to actually try to change the environment that we work in?
Pooja Lakshmin: [00:45:49] Yeah. So. So the fourth principle is that this is that the work of real self care is actually about power and who has power and who has agency and who doesn't. And sort of always keeping in mind that we are fighting against these oppressive systems. And so to your question, Henry, about an example, so in the book I talk about stories from my practice. And so, for example, a patient who, through the work of real self care, starts to set boundaries, starts to develop self compassion through that, understands that she's actually really resentful and angry that her husband has never taken a paternity leave despite them having two children and so has some really hard conversations with him. And he asks his employer for a paternity leave when she's pregnant with their third baby. And his employer surprisingly grants it. And so that change and his workplace will then benefit everybody else that it comes through at that job. So it's actually interesting because my patient wasn't setting out to like be an advocate or do something like that. Like the work of real self-care is actually totally personal. But when you go through these steps and you start making different choices in your own life, that empowers the people around you to behave differently and ask different questions and make different choices. And then that leads to a cascade effect. So even as we're kind of talking about here on this conversation, like Henry, the honest conversations that you're having with potential premed students who reach out to you, the fact that you're, you know, actually being real and honest is creating change, right? Because you're helping them see like, wait, what is really important to me, I do that in in supervising and mentoring residents at GW and also mentoring other women of color physicians who are trying to get into writing or entrepreneurship.
Pooja Lakshmin: [00:47:50] So I think like the best type of advocacy is like the one where you're not necessarily trying to do it to be an advocate, but that you're just doing it to help somebody else empower themselves. And then along with this, you know, just kind of like to touch on my own journey as well. Like, I always like to be really transparent about like, you know, the fact that I could leave full time academics was because I had a partner, have a partner who has a stable, employed job, and I could be on his health insurance, right? Like there's these structural constraints too. And especially for physicians, if you have a ton of student loans, if you have a huge mortgage, right, Like there's all these things that come into play in terms of like the decisions that you're able to make. So. I think we have to always keep in mind how power is distributed across individuals and inside systems. And when you are somebody who has advantages or has privileges to pour that back into others, you know, that's really the work of community care.
Tyler Johnson: [00:48:57] Yeah, I remember. I was telling Henry the other day that after I worked so hard to get into medical school, about a month before I started medical school, I had this sort of dream as I was falling asleep one night that I was at the top of a snow covered hill on an old fashioned sled. And the sled was sort of teetering at the, you know, just about to tip so that I would start down. And then as it teetered far enough forward that I could see the mountain in front of me, it turned out that it was not just a hill, but this huge, long, super steep mountain. And the idea that I had was like, once the runner's caught and I started down the hill, there was just no stopping it, right? Like, I mean, because once you have even a couple of semesters worth of med school debt, like what are you going to do, quit with $50,000 debt and no degree, right? I mean, it becomes this sort of inexorable process. And then even once you graduate, as you say, unless you have some other very lucrative job opportunity that's not being in medicine or you have a partner or parents or whatever, but some other place to fall back on.
Tyler Johnson: [00:49:56] If you graduate with a mortgage's worth of debt, you're sort of, you know, bound to the system whether you want to be or not. Right. And it's it's a very it's a really daunting prospect. I think it should be a daunting prospect. Right to the point that Henry was making earlier about I've done sort of a similar thing where I go back to my alma mater, where there's no medical school now once a semester to give them a like a lecture to the pre-med seminar. They're called Counting the Cost, where I talk about all of these same things. Right? Because it's just I mean, and I'm actually I have a pretty romantic vision of medicine. Like, I still love most of what I do and find it to be deeply fulfilling. But you have to really understand what you're getting into because it's a lot and it's not something that you can easily just pick up and walk away from.
Henry Bair: [00:50:43] At the end of all of this, you have offered so much advice for not just really medical trainees, but people in general who are going through a lot of stress and hardships in whatever industry they're working in. But bringing it back to our listeners who are mostly current trainees, young clinicians and future doctors and future educators to anyone who might be working in the health care system. What advice do you do you have for them to start? Getting better control of their self care and how how can they start on this journey?
Pooja Lakshmin: [00:51:22] Yeah, that's a great question. The word that comes to mind is agency. I think when you're a medical student or when you're an intern, when you're early on in your training or your career, it's really easy to feel like because you have these big goals for yourself, that things are being done to you and that you don't have any choice or say in the matter. And so, you know, when you're at the bottom of the totem pole, I'm not suggesting that it's possible for you to change family leave policy or like, you know, sort of take on these big, big asks. But it could be really small things like I'm going to eat breakfast in the morning before rounds, like I'm allowed to eat breakfast. I'm going to go to the bathroom when I have to use the bathroom, you know, like understanding that you can respect yourself, you can give yourself that respect and those small moments like that actually adds up. The other thing that I would say is like. So I know a lot of people give this advice, but I think it's really important is like really try and keep other people around you who are not in medicine and who are not in you know this.
Pooja Lakshmin: [00:52:39] Terrible conveyor belt that you might be on because like, it's so easy to get sort of caught in the toxicity of like the rat race of everybody's trying to do. And I will say, as somebody who's gone off the beaten path and like doing outside the box stuff, like in the beginning when you start doing stuff that's different, like everybody's a hater and everybody's like, Oh my God, what are you doing? Like, that's so weird. Why are you on Instagram? And then once you get a little bit of success, everyone's like, Oh my God, that's so cool. That's great that you're doing that, you know? So I think like. Trust yourself. And like if you're if you want to explore, like your creativity or writing of entrepreneurship, whatever it is like, let yourself follow those threads. Even if your med school friends think that they're a little bit weird and that you're a little bit weird because that's going to be your superpower.
Tyler Johnson: [00:53:30] And I think with that one thing that I've discovered. Henry talked about what it's like to be at Stanford Medical School. You know, it took me a long time to realize that even places as supposedly altruistic as medical schools have self-interest, right? Like they have things. And when you come in as a medical student, you know, they bill themselves as being all about your development and your success, which is true sort of. But what they don't tell you is that they have a very specific definition of success because they want your reflected glory, in effect. Right? Like that's really what they're looking for, is they want your publications so they can say, look how many publications our medical students have, Right? Which is important to recognize because if you break out of that mold, that may not fit what your success may not fit what they think of as success. And so you may also get institutional pushback, whether you're in a residency program or a medical school or even once you have a job, right? Like it's about that alignment of values that Henry was talking about earlier. You have to recognize that institutions also have success metrics. And even if you are phenomenally successful, if it's not the kind of success that they want, you may get sort of, you know, dirty looks or sort of offhanded words from the people in power because they don't like the way that you're succeeding.
Pooja Lakshmin: [00:54:45] Right. I think there's that great article that I'm forgetting where it was now, but it was like, you know, the institution is not your friend. The institution will never be your friend.
Tyler Johnson: [00:54:54] Who will not love you back.
Pooja Lakshmin: [00:54:56] Right. It will not love you back. Exactly right. That's a classic. So everybody makes sure they read that, too.
Henry Bair: [00:55:03] But ultimately, to your point, I like that you end your run through of the principles with saying that this is in its own way power, Right. I found it inspiring how you say that sometimes the best advocates are the ones who aren't trying to be advocates. They're just trying to spread the good that they found in their own work and lives. And sometimes that can be very powerful, more powerful than we anticipate.
Tyler Johnson: [00:55:28] I love, too, that your life has demonstrated the way that you have taken that power, right? Like that. You sort of left somebody else's version of medicine so that you could come back to the version of medicine that is the one that speaks to you.
Pooja Lakshmin: [00:55:43] Thank you. I really appreciate that. It means a lot to me. I'm always worried about how people in medicine will judge me. So, yeah, so I appreciate that. And you can keep that in. I'm totally fine with admitting that.
Henry Bair: [00:55:59] Well, with that, we want to thank you again for your time and for all of our listeners. Definitely check out Pooja's new book, Real Self-care, which we will link to in the show notes to this episode.
Pooja Lakshmin: [00:56:09] And my company is Gemma. Gemma. Gemma Women.com. We are a women's mental health community and we have a weekly newsletter courses and WhatsApp thread and all sorts of ways that you can engage. So yeah, I would love to keep in touch and it was such a pleasure getting to chat with you both and I hope to come back again and talk more.
Tyler Johnson: [00:56:32] Thanks so much, Pooja.
Pooja Lakshmin: [00:56:33] Thank you both. I really appreciate it.
Henry Bair: [00:56:37] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:56:56] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:57:10] I'm Henry Bair.
Tyler Johnson: [00:57:11] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.

Leave a Reply

Your email address will not be published. Required fields are marked *