19. Ni-Cheng Liang, MD: The Powerful Practice of Mindfulness and its Healing Benefits

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Make no mistake, digital marketing is a science. Advice media has created a proven roadmap that gets you from where your practice is now to where you want it to be. They call this their pyramid of success. Thousands of clients have proven that their six-stage approach is the optimal way for attracting new patients and retaining current ones. We get it, you're busy and don't have the time to be a digital marketing expert. You have lives to change, give them just 30 minutes to console with you. They would bet you are doing some things really, really well, and there might be areas where you can improve. That's where they come in. Just for spending time with them, they will give you a $60 Amazon gift card. You have nothing to lose. Book your console today, go to Drpodcastnetwork.com for slash advice media. That's Drpodcastnetwork.com for slash advice media. All right, everybody. Today, our guest is Dr. Nhi Chang Liang, an integrative pulmonologist in San Diego, who has taken the practice of meditation to heal herself. In this episode, you'll hear Dr. Liang talk about what it means to be mindful and in the present moment and how that term differs from meditation. We delve into how she incorporated mindfulness in her own journey as she battled cancer. For those of you who may struggle with starting the practice of meditation, we even discussed the science behind it and all the amazing benefits. And lastly, as practitioners, how can we exactly talk about mindfulness with our patients in only 15 minutes? We get to that as well. So deep breath in and deep breath out. Let's begin. All right, Dr. Nhi Chang Liang. How are you today? I'm good. Thanks for having me. Yeah, absolutely. Thank you so much for coming on. So I'm super excited about this topic, mindfulness. It's something that I've been learning. I've been practicing for quite some time now. But I think for a lot of people as individuals, this is such a great area. It's something that I think every individual tries to grasp or tries to understand, but because there's so many different perspectives, we tend to get lost. So in your terms, let's just get right into it. What is mindfulness? Sure, mindfulness is paying attention on purpose to the present moment without judgment. Wow. That was. That was verbatim. I like it. So repeat that again. It's brief. I love it. So it's basically John Kabatzin's definition of paying attention on purpose to the present moment without any judgment. Wow. Wow. Exactly. It sounds very just on the surface, but there's so much meaning to that when you break it down like that. How do, how many definitions are there of mindfulness, right? So is that the only one you subscribe to? Is that the only one you tend to practice or think of or is there anything else? Yeah. That's a, that's a great point. So the, the other one that I like is the state of being when you're mind and your body are in the same place at the same time. Okay. Yeah. Absolutely, right? So it's, it's again, it's about being in that present moment. Now, can you at least talk about why it's so important to be in the present moment rather than anywhere else if it's past or present or sorry, past or future? So if you aren't in the present moment, then you're not really living your life. We spend way too much time in our heads, especially in healthcare. We make hundreds if not thousands of decisions every day, cognitively. And yet, how many times have we actually sat down and checked in with our own bodies, with our own emotions as we witness suffering, oftentimes we're like living in the past, catastrophizing about the future or thinking about the future and potentially wishing things were different than they actually are. And so there's a lot of suffering when you live in the past or in the future, when really the most important time to be living is now. I love that, Nisheng. I mean, I know, as you mentioned, all of us healthcare providers are making these hundreds and thousands of decisions and it's not just unique to us. I mean, individuals in every field tend to do that. And I'm guilty of this myself. I'm always thinking about the next thing. What's the next step? We're all planners, right? And it's all just next step, next step. And you got to get to the goal and the next goal was the next goal. And so I want to talk more about how to practice that art and really try to perfect it and hone on that craft. But maybe just since we were talking about definitions, a lot of times people use the term meditation and mindfulness interchangeably. And I don't think that they're necessarily the same thing. So maybe just so we can lay out those semantics a little bit further, if you could explain the difference between meditation and mindfulness. Sure, so mindfulness is like a state of being in that way of paying attention to the now without any judgment. And that state can be cultivated or you can train yourself to be more mindful by using meditation as a vehicle, similar to exercise to increase aerobic capacity and build muscle. So meditation is the exercise for the brain in which you can learn to be more mindful. Yeah, absolutely. And you know, later on in this episode, we can definitely get into kind of how you teach that. But tell us a little bit about your journey. How did you come to understand mindfulness? How did you really get into this practice? Yeah, so I was born and raised Buddhist. So there were little tidbits of Zen meditation kind of intersversed throughout my childhood. However, it wasn't until I was diagnosed with cancer in my second year pulmonary critical care fellowship that my body literally made me stop. And it was a message loud and clear that I heard as if I kept going 200 miles an hour, my body would literally put me in the ground. Because my stress levels were such that the lifestyle was living was unsustainable for health and wellness. And so actually during a cancer survivor day at the Cancer Center that I was getting my treatment at the founding director of the UCSD Executive Center for Mindfulness basically came and gave a talk and really resonated with me. And I knew from that moment I wanted to learn it, to teach it, to practice it. And that's been practically like 10 years in the making now. So with that, I started off with mindfulness-based stress reduction to the foundational course, if you will, for the cultivation of mindfulness. And three cycles of taking that later, different teacher trainings and mentorship programs. And even also doing some training over at University of Rochester's Mindful Practice programs with Ron Epstein and Mick Krasner during one of their teacher training intensive retreats. Over the last couple of years, I've been teaching it much more regularly as part of my day to day. Yeah, I mean, that's crazy. And I remember listening to one of your episodes of where you talked about when you had gotten that diagnosis, I think you had a biopsy done and the very next day you flew out to an American cancer thoracic society, meaning to maybe do a presentation or something. And it's just like, to me being in this healthcare field and being a resident right now, it didn't surprise me at all. And somebody might say, what the heck, you just got on the plane and jumped out there to go to a presentation. But it's just, again, going back to that, we're onto the next thing, right? And a lot of times, we tend to just sacrifice our health and we're not even, we're putting that on the back burner because you're trying to care for a patient or you're trying to advance your career or whatever it is that you're trying to do. But I'm curious, you mentioned that there was that one presentation that you heard something really, excuse me, something really resonated with you. What was it specifically about that presentation that almost turned this switch from off to on that you were like, okay, this is kind of my calling. Whatever I'm doing right now, I know it's obviously your own medical illness, but something specific about that presentation because this is the second time I've heard you mentioned that. I think that it is the potential health benefits that it has and that it can make us more joyful and it helps us to basically align our mind body and souls in a way that is not just good for our health, but also good for the people around us and potentially has benefits for the patients that we treat as well. So I saw it as a nugget of wisdom for a potential healthier option in how to live life that transcended beyond just that particular moment that I saw it as something that I could embody and live and then teach and kind of like in my own podcast, we talk about the ripple effects of mindfulness, spreading that out into the world to potentially make it a better place. So would you say that was the tipping point at that point where you realized, okay, I got to kind of get my life together after going through this busy, busy, busy schedule and not really taking care of yourself? Yeah, absolutely. The cancer diagnosis really reshaped the way that I self-care and really you cannot take care of others unless you care for yourself first and foremost. Yeah, absolutely, right. We always talk about, we got to fill up our own cup before we can fill others. But as a pulm crit fellow for those out there, you're taking care of these sickest patients in our healthcare system, right? So what was the conversation in your head taking care of the sickest patients but then having a diagnosis of cancer, was it all doom and gloom at what point did you become somewhat optimistic? Can you kind of take us through that dialogue, that internal dialogue you had? Sure, there is a lot of catastrophization because the way that I received the diagnosis was after my poster discussion session from the American Thrasic Society meeting, I received a phone call during lunch and had never been more scared in my life when I heard the words you have breast cancer. And the fact was that we didn't know anything about the tumor type, what stage it was, what the treatment plan was going to be, and of course, especially in healthcare, we're trained to think about worst case scenarios and prepare for that on behalf of our patients. But when it happens to you, that kicks in and there was immediate catastrophizing. So I dropped everything, canceled the rest of the conference and the hotel flew back on the first flight out back to San Diego to really be with my family while we awaited the advice of the next steps from my physicians. And is that when you kind of started through the process of going through treatments and what was that like? Yeah, so I enrolled in a clinical trial called the ISPY2 trial, which is still actually enrolling and I was part of a New England Journal of Medicine article, I can actually point myself out on that article because I was one of very few Asian participants in that clinical trial. And so there were doctors appointments after doctors appointments, especially with the clinical trial enrollment and I got a second opinion. It was kind of a whirlwind, honestly, getting all of the ducks lined up in place for the treatment plan and the course. And then it ended up being like five months of a really, really tough chemo regimen, lost all my hair, including my nose hair. So I have like a very, very keen gratitude for those hairs in general, otherwise I had like chronic running nose all the time. And underwent so neo-adjuvant chemotherapy for those five months. And then I had bilateral mastectomies with reconstruction, which ended up being like three more surgeries. So I took a year off of fellowship to do all of that and really not only kind of care for myself on the outside because my scars from surgeries, my port placement, they were all healing, but also taking some time internally through talking with an oncology therapist to help me through processing everything that I had gone through and then incorporating mindfulness to help deal with the anxiety of the uncertainty once treatment was over. Absolutely. So you're going through treatments, you talk about adjuvant treatment, how did you incorporate mindfulness? Did you have a routine and what were you hoping to gain out of that? Yeah, so I initially started more with mindful movement from yoga. So I was doing like gentle yoga practice pretty regularly and making sure that I was doing it outside. One of the things in training was that I realized in retrospect during cancer treatment that I definitely wasn't getting outside enough even though I was doing my fellowship training in San Diego. So doing that outside and that was how I initially incorporated it. And then after that, there was just the immersion into the Mindful and Space Stress Reduction program itself, where it was basically a nine week commitment for the course with 45 to 60 minutes of formal practice every day. Yeah, I mean, just something that you said that kind of strikes out to me out there is, you know, a lot of times when some individual goes through this adversity, right? We have a medical illness. You talk about the scars and the trauma and all that. That tends to heal for the most part. The true healing though comes from within and I think I've heard you and your counterpart on your podcast talk about this is that all that stuff is going to heal. But if you're not healing from within, then the internal scars are going to make you sicker for the long run. You're not going to truly recover from whatever ailment that you're struggling with, right? And it sounds like mindfulness was your tool or one, your strategy to help you and you continue to use that today because you've talked about this concept of scans ID, which is a term that I've only heard you talk about and it's interesting. And it makes me think about in our profession for Darshani, we're a physiatrist, right? So we see a lot of individual with spinal cord injury, we see traumatic brain injury for all these disabilities and amputations and those kinds of things. And again, they have these life changing diagnoses now when most of the time that there really isn't bouncing back from. And so maybe they can heal on the outside or maybe they can come to this new way of life for, let's just use spinal cord injury as an example, we know that depression, anxiety and these mental health disorders are, the prevalence is really high for individuals, you know, a common thing that we learn about in medical school is older individuals. A lot of times, you know, they are pretty depressed and you're like, okay, don't, you know, or they appear to be down and they're depressed, but you don't want to mistake that for some type of, you know, cognitive disabilities and vice versa and those kinds of things. And it also reminds me about, you know, in spinal cord injury patients, suicide is the second leading cause of death, especially for individuals younger than 25. So it's not something that to be taken lightly and that's where the mindfulness component I think in our practice that we could use so much more is helping those individuals heal from within to try to accept or make the most of the new terms that they have that life is given to them. And yeah, I mean, I think about that and I'd love to hear your thoughts about, you know, again, your pulmonary cord fellow and now you're obviously, you're not a fellow anymore, excuse me, you were a fellow, but now you're a pulmonary cord doc and you're seeing a lot of individuals who might have had this disability from COVID, long COVID, those kinds of things. Is there a role for mindfulness and that healing from within that you've talked about before? That's such a great statement, ultimately, yeah, I've seen now probably hundreds of patients who had COVID from various age groups, various clinical consequences, mental health consequences. And so we know from medical literature that mindfulness has over 9,000 articles published about it and in the pulmonary realm we know that there's positive studies looking at asthma, some in COPD, addiction, like smoking cessation, insomnia, and then also anxiety and depression because also in chronic lung disease, not excluding COVID because I think we're going to see more literature about that, but like we know that anxiety, depression or comorbid factors in, for instance, COPD, chronic obstructive pulmonary disease and asthma, anxiety is a huge trigger for asthma. And so yeah, the literature shows that definitely can help with basically improving the quality of life of these patients who have chronic diseases in helping to tamper down perhaps the anxiety and depression component of it, but ultimately there's something that happens on a physiologic level at a neuroplasticity level that occurs that ends up not just helping their brain, but also the rest of their body, like their immune system, their ability for digestion in some cases, their cardiovascular health. So I think that even though mindfulness in and of itself is a practice for the brain, it's far reaching, but because it is a practice for the brain, it is a potential healing staff internally for people with chronic illnesses, and also people who just want to improve upon their well-being because stress is ubiquitous in day-to-day life. Yeah, absolutely. You just touched on some of the science, the neuroplasticity, the cardiovascular benefits. Now, I think a lot of people don't feel those things. It's not something that you meditate or do yoga for 30 minutes and then boom, you start to feel those effects, and I think that's why a lot of people, I want to say stay away, but they don't continue that practice. They're not consistent at least with mindfulness. Now, as you were going through your journey, being a doctor, were you looking at the data, were you looking at things and seeing how they can affect a human physiologically, and if so, can you kind of break down what some of those things were showing? Yeah, so from asthma perspective, for instance, there was a positive study looking at short-acting inhaler use. So asthma patients need their short-acting inhalers if they have increased shortness of birth, easing or cough, and with those patients who had undergone mindfulness training, they didn't need to reach for their short-acting inhaler any more as much. So, and then when you look at like quality of life asthma scales, same thing, their quality of life improved. They were no longer as symptomatic overall. So just that's a snippet from like the pulmonary world. From more the immunology world, small studies, but still pretty compelling, where mindfulness practitioners got like an immunization, and their immune response was actually higher than that of non-mindfulness meditators, for instance. So there's a lot of psychonural immunology that is getting published, and I think we're just at the tip of the iceberg for some of this physiology. But we know that the practice of mindfulness upregulates our parasympathetic nervous system, our rest and digest nervous system. It upregulates vagal tone, especially in the era of COVID. There's a lot more stress that's prevalent, so many more people are in fight or fight mode a lot more, and we need to like rebalance the nervous system into more rest and digest. Absolutely. So do you think it's mainly just the signs behind parasympathetics? I know like breathwork, for example, which I'll do all immediate, immediate effects, right? Just right away. We're going to acupressure mat, honestly, at like 5am, right before I go to the hospital, I drive, I'm on my acupressure mat on some days, and I just feel my anxiety just kind of wash away. So is that kind of what the backbone of the theory is with mindfulness? Yes. But there is also something to be said about an intentional habitual practice, this installation of a ritual for wellness, that supersedes that of just like the physiologic benefit of mindfulness, right? So if we incorporate ritual in our day-to-day and our wellness rituals, whatever they may be, like your acupressure breathwork, which I incorporate a lot with my patients, I add the mindfulness to like perslip breathing and guide them through that in a clinic visit, for instance. That can be just as powerful or has a potential to be just as powerful. Consistency and making it ritual, I mean, I think that we've talked about darshan, I've talked about consistency, you know, over perfection all day, right? I mean, that's kind of what beats it, no matter what your goals are when it comes to being consistent with nutrition, exercise we've talked about, mindfulness, sleep, all the basically the foundational pillars of health that we talked about, often on this show, the issue is time, right? I used to be in this camp a couple of years ago, where again, being a medical trainee, you know, you're sleep deprived, most of the time, and I'm okay, I got to do mindfulness and be five minutes at 10 minutes a day, and then I would think to myself, well, that's like 10 minutes a day that I could sleep extra. Why wouldn't I just do that? And it wasn't until I started doing it on a consistent basis that I was able to appreciate the benefits of, again, being present, one of the very first things that you mentioned. So my question for you is, let's just say it's a novice, right? A novice individual that you're trying to convince maybe in your clinic practice, hey, maybe this might be beneficial for you on a day-to-day basis. You might not see benefits immediately, but maybe long-term down the road a couple of months or so. How would you advise them to start off? Would it be a minute a day? Five minutes a day? Ten minutes a day? Like, how does one incorporate this into their daily, just being more mindful in their practice? It totally depends on the patient, but it can start with just using breath as an anchor. So encompassing some of the breathing exercises that they're already taught in pulmonary rehabilitation, for instance, but using that person breathing more as a practice that they can incorporate every day as opposed to just when they're acutely short of breath. So even just three breath cycles, right? Three per-slip breath cycles. So I invite them to try it as a practice. The other aspect is that one can be introduced to mindfulness through informal practice. So when there's an intentional placement of attention on something that you're doing, something as simple as washing dishes, showering, noticing the sensations of water, even our hand washing in the era of COVID, we're like hand washing so much more. Those are all opportunities to notice the sensations of the gel, the alcohol gel, or the soap, and the water running over our hands. It's an opportunity to like hit some acupressure points when we're doing a hand massage with washing. So it depends on the patient if they're ready for some formal practice. Then I give links to sites and apps to just check out, poke around, and be curious about. So it starts with like peaking their curiosity about it, and then also giving them the opportunity then if they're not ready for something like that to try some informal practices where can pick like hand washing or even brushing one's teeth. Like my fellows can be applied to doing anything or not doing anything, anytime, anywhere, and can be something that can be practiced by anyone. I love that. I especially love the fact that, you know, how little that you actually have to do to incorporate that. I mean, you mentioned three breath cycles, right? I mean, depending on how long that cycle is, it could be 30 seconds tops. I remember actually not too long ago coming across a study, it was a systematic review. I think there weren't a lot of trials that they had evaluated, but it was north of a thousand patients that they looked at. I think they evaluated ultimately the effects of diaphragmatic breathing and its effects on physiological and psychological stress and basically what they had, they had two separate groups and it was like kind of an eight-week trial of one group that independently, there was no other intervention it was paired with. It was just diaphragmatic breathing. I forget exactly how they co-stero-cute them to do that, but what they found ultimately were that at rest, the group that incorporated 20 sessions over eight weeks of diaphragmatic breathing had decreased resting breathing rates that were measured during sessions. They also had measured their salivary cortisol levels that also decreased over time, whereas the control group, they didn't have those changes. They also have found that the systolic and diastolic blood pressure, kind of what you guys have talked about, the cardiovascular benefits improved in the deep breathing group, whereas in the control group, that didn't happen. And then, of course, the perceived stress was much lower and that's objective. So it's much harder for an individual to kind of manipulate their own blood pressure, right? So that was something that really stood out to me. It's like, wow, this is pretty profound and it was as little as eight weeks that people were able to see these effects. So that's pretty impressive. I think most people understand, hey, high blood pressure stress, we don't really understand that, and high blood pressure stress equals stroke sometimes in a very, very, very basic level when it comes to in our world, limpium and arb, I thought that was really interesting. I want to go back to this concept of being present though, because you've kind of talked about it in different ways, right? Brush on your teeth, washing the dishes, just even washing your hand for those 20 seconds, instead of maybe singing the birthday song, you're kind of just filling the soap on your hands and that kind of stuff. Again, it is hard to do in this world where we're just go, go, go, go, go, right? So many different things are fighting for attention. It's my phone with my notifications. I got the Instagram, I got Twitter, this happening, TV's on in the background. I'm thinking about the patient, maybe I saw earlier in the day that didn't maybe go as well, but the procedure I have to do tomorrow. And again, it's not unique to medicine that this is applicable to everybody in every profession, right? How do we completely disconnect from that? I mean, is finding the anchor is one strategy? When you have these stresses that again, everything is kind of seems urgent all the time, right? And then you also have people who are asking for attention, you're loved ones. Other than maybe just finding those brief moments in life, how do you just kind of put those, like, stretch that out where you can have greater times of being present in the moment? Does that make sense? I think it comes down to intention. So when practicing mindfulness, one of the big challenges, especially during such an intense course, like mindfulness-based rest reduction is that people are coming into this course with like time scarcity. There is an attention, or sorry, an action bias that many of us have, that we have this constant need to do, do, do. There are so many things that can take up each second of our lives, that if we don't come to how we spend our time with intention, then it will become all consuming that you're not practicing mindfulness. So it comes to the point where you decide for yourself because how you spend your time, it's all about choices. And when you see that you do have a choice in how you spend your time because you're intentional about it, then I think things can start opening up for you in ways that might not have seemed possible before. For instance, like being mindful of your media consumption, like screen time, especially over this past year, with schools going on Zoom, and all of the news, and how addictive that can be also a social media and smartphones. If we're intentional about shutting that down and sitting with ourselves for however many minutes a day, and it doesn't have to be practicing mindfulness meditation, it could just be sitting outside and noticing nature. It could be walking outside from our clinic to the hospital mindfully. You can build in the intention for attention on the present moment, but it won't exist unless you purposefully seek it out for yourself. So you have to make that decision for yourself. It's a choice point. It's not going to happen automatically because what's going to be automatic is your default mode network where you're just busy all the time. We wear this badge of busyness. How are you today? Oh, I'm busy. And if you say you're not busy, are you not working enough? There's something wrong if you're not busy. So wanting to shift that paradigm where you get to be very intentional with your time, I think it's going to be the key in terms of how one can practice mindfulness. It's a big decision. It's not an easy thing. Like, practicing mindfulness goes well beyond that of just noticing the present moment. It's a consistent practice. Yes. And we have to kind of retrain our brains to be able to do that. Yeah. In type A individuals such as ourselves where all we've been doing for years and years, it's just you're doing, doing, doing your constantly doing some type of activity because you need to, right? And what 10, 15, 20 years that you're kind of building up to becoming a doctor. And then now we're trying to retrain our brain. It's challenge. I mean, we know that those, the neuroplasticity, it's the likelihood your brain's not as malleable as you get older, right? I mean, those, those synapses have kind of laid a good foundation. It's going to be much harder to rewire them. But something you mentioned kind of reminds me of a conversation. I remember forget where it was, but I think Ryan Holiday was talking to Tim Ferriss about this, at a time in his life when he was part of a workaholics anonymous. And you know, he was saying that he wasn't as, as much addicted to work, but instead addicted to activity. And again, this goes back to this idea that today, you know, often people are, especially the younger generation, because they're so, they're always doing something. And I put us in that category as well. You know, we're always about the next activity. Again, media, social media, things that are asking for our attention. Sometimes people get misdiagnosed or mislabeled as having ADHD because they're jumping from left and right. And it's not, again, it's being addicted to activity and cost and stimulation. And I'm guilty of that. I think that this is exactly why, for me, disconnecting has been so incredibly important. Because again, another conversation I remember him having, again, Ryan Holiday talking about how it's called human being, not human doing. And he related to, I think now he lives like on a farm and he's talking about how, which is one day he was coming home. He just saw his goats just standing there not doing anything. And he was just like, wow, that's, that's remarkable. Like we would never do that. Most people, especially as type A's, we were like, I got, I'm wasting my time, right? And I personally find myself that when I have those down times, whether it's a drive or I'm washing dishes or I'm cooking, I'm either listening to an audiobook, I'll throw on a podcast or throw something on because, you know, it's, it's, that's time, that's valuable time. I could be learning something. I could be doing something else. And now it's very much a conscious decision that I have to pause. And when I'm doing something, be mindful, hey, I'm going to fold this laundry. It's torture. Let me tell you in each eye, it is hard to do. And, and I've, you know, I'm, I'm, that didn't go just 100% all in, then I no longer listen to podcasts or audiobooks because I do think you have to find that balance. But I think that that's something that's especially hard when you're always addicted to doing something to, to say, oh, hey, I'm going to completely be mindful and be alone with my thoughts and just sit there and not do all these other things, not have TV on in the background. It's super hard. But I think if someone's curious about it, they know, they don't know what they're capable of in terms of like their ability to be truly in the present moment, not multitasking unless they actually try. So I truly believe that everyone can be mindful. Yeah, absolutely. You know, Nietzsche, you brought up this point about how humans wear this badge of honor about being busy, right? Because we equate busy to being productive and we equate being productive to social status and financial status. And it's, it's almost as our self-worth, right? And I just want to mention, I don't know if you've read this, but there's an article called Lazy a Manifesto. And it's just a beautiful article that talks about how we need to stop labeling ourselves as busy. And it's okay to not do that. And again, for the listeners out there, I'll link this into the show notes. But you know, right now I'm in my intern year. I have two months left and you guys know how tough intern year is. You guys have been through it. So often medicine, we're taught, hey, there's light at the end of the tunnel. You know, you're going to get there, you know, you get more pride, you get more status as an attending, you make more money, right? And for me, I have two months left. And I can definitely see that light at the end of the tunnel going into PM and R. But you know, oftentimes, though, in my workflow, I'm so disengaged, right? Like I don't really have that intention, like you're talking about. And I'm burnt out. I'm truly burnt out. And now we have this whole definition of burnout, right? We have this whole issue in the healthcare system about burnout. What is burnout to you? Burn out to me is when there is the type of soul sucking exhaustion that exists that is not able to be remedied with just taking a vacation or just taking a nap. There is a moral injury that has accumulated over time to the point where there is so much mind, body, and spirit exhaustion. That's my definition. But we know, you know, Christina Mazzlock's definition of burnout as emotional exhaustion, depersonalization, and low sense of personal accomplishment. Sure. No, I think I've experienced all of that. The moral injury to the depersonalization, you know, definitely during this year, especially being an intern during COVID. I mean, it definitely hasn't been easy. But why is it, you know, and I guess we can break this down in many different ways. But in the in healthcare as of recently, you know, I've seen a report saying about 50% of physicians have been burnt out. I'm sure that numbers way higher. Why is it that we're seeing so much burnout in today's practice? I think that the way that medicine is practiced now is not conducive to also healing the healers. Like we have a disease care system as opposed to a healthcare system. I think that there's an industrialization of the practice of medicine in a way that is not conducive to the health and wellness of the healthcare professionals that are trying to heal others. Yeah. And, you know, the discouraging thing about that, I remember, well, I guess I was like 2012 that I was going into medical school. And I remember reading an article at that time that 9 out of 10 doctors would not recommend going to medical school. In fact, most of the physicians that I was shadowing asking, you know, talking about, they were like, well, why do you want to go to medical school? You know, in tone that would say this doesn't sound like a great idea. Financially, it's, you know, if you can't afford to pay for it, taking out the loans, I think that most of us can agree that's probably not a good financial investment. And that's not the reason why anybody should do it. I think most people agree with that. But how do we get to talking about healing the healers, right? I mean, we talked about you, for you, it was that, that switch that turned on. You were like, okay, I'm at this breaking point. This is not sustainable, right? This is not that's going to happen. And I don't know if you would agree, but I think that the three of us having this conversation, I would say, I would consider ourselves fortunate, because we had this realization, because that's step one, we acknowledge that this is not a good way to do it. We need to find a better way. A lot of times people don't come to that until way later in life, when it's maybe too late, or, you know, they don't find that in residency training or maybe early on during fellowship, kind of like you did. So how do we go on talking about healing those healers or encouraging our healers to actually think about filling their own cup first? I think we are doing it. We are being the change that we want to see, right, with your podcasts, my podcasts and the Mindful Healthcare Collective work, especially over the last year. I think medicine is at a tipping point where losing one physician a day on average to suicide is not something that should be the norm anymore. That being in medicine is hazardous to one's health because the rates of suicide are more than two times higher for women in medicine than the general population, like that's ridiculous. That should not be the norm. And yet, right now, that's the norm. And probably after we come out of COVID, we're going to see that it was worse, that burnout was worse and is worse during COVID. So I think that having open conversations about it like this, spreading the word, being part of the ripple effect, perhaps being a pebble or a big rock that makes a big splash to disrupt the narrative of how medicine is. And in my respect, in my story of how I practice medicine now, I don't necessarily practice it in the usual way, if you will, because coming to the realization of 20-minute visits, 15-minute visits per patient, constantly being on this hamster wheel of productivity, it wasn't filling my cup as a healer anymore. I felt like I could not help patients to the extent that I wanted to help them. And so income's mindfulness, income's this desire to want to get to root causes as opposed to like constantly putting band-aids on people and then having it be this revolving door. So for me, mindfulness has been kind of that point where I was able to bridge not only my own needs as a healer, but to also help heal my patients in a way that was more at the root level. So yeah. Yeah, no, you are speaking our language, right? You nailed it when you said this is a disease-care system, right? And our motto is putting the health back in healthcare. So I do want to get into how you teach. You know, you you call yourself a teacher. And so I'm very interested in, you know, in this 15-minute system we have, how have you formed your teachings? How have you conveyed this message to your patients, especially as a bunch of us are trying to learn mindfulness? I know me and Ultima are very into root cause medicine. And at one point, that's the way we want to practice. So we would love to learn from you as to how you do that. Yeah, so to be fair, I'm lucky in that in my practices, I've had 20-minute follow-up visits, but I know that my like primary care physician colleagues have had not had the luxury of those extra five minutes. Even still, even within a 15-minute 20-minute follow-up visit for a very complicated patient, I still believe that you can build in even just a one-minute practice with the patient. And that really is first checking in with the patient to see if they would be willing and open to experiencing it with you. And then leading them in a brief guided practice where the breath is an anchor. But if I know that some of my chronic lung disease patients focusing on the breath as an anchor is stress provoking. And that's okay. So we can offer different alternative anchors of attention, like noticing the sensations of our hands in our lap or noticing the support of the ground beneath our feet. So like literally focusing attention on the feet as a grounding point, as a focus of attention for the mindfulness practice. So we can, I can demonstrate if you want me to, but if not, then we can, and then after I lead them through that practice, I ask them how they're feeling. And I don't think I've had any patients say, oh my gosh, that was horrible. I'm like way more anxiety written now than before the practice. Like a hundred percent, you're like, oh, I feel calmer, I feel more grounded. And it's empowering to them to know that they're able to come to that state on their own. Like I didn't give them any pill. I really just help them focus their attention and harness their own physiology. So there's an empowering thing that happens when I teach someone how to practice mindfulness. So you mentioned, you know, practicing and teaching our physician colleagues and our healthcare providing colleagues by using these platforms, right, and education. And staying on that thread of education, I think another way to do it is to kind of help build it in the curriculum of medical schools, right, and in residency and very much something that you did. I think from somewhere I saw that you were part of this curriculum development over at UCSD for mindful communication. Is that correct? You mind talking about that a little bit? What it was that the purpose of that was and what came out of that? Sure. So UCSD started incorporating mindfulness in the practice of medicine course a couple years ago. And I was lucky enough to be part of one of the revisions, if you will, to some of the modules for the curriculum, the how to be a doctor course. So every other week the med students in their first and second years would have mindfulness practice embedded into the curriculum. And so looking back at my own med school curriculum, I wish I had that. And I think that it's so great to see so many more medical schools embed mindfulness into medical school. And I hope to see residencies also embedded. So in terms of the mindful communication curriculum was under the auspices of getting permission from my mindfulness teachers Ron Epstein in the Krasner, really the seminal pioneers, if you will, in the physician world of bringing mindfulness into clinical practice. So they wrote a seminal article in JAMA published in 2009 where they used a mindful communication curriculum that they had created and had I think it was like 50 something primary care physicians go through this curriculum with CME. And burnout was reduced reductions in anxiety and stress. And then the results were that even a year out, 18 months out from the intervention, the results were still quite persistent. So there was definitely a shift. And so in training with them and learning how to teach that curriculum, I taught the med students as part of a elective. So there was a mindfulness and medicine elective. And I brought the mindful communication curriculum to that course. And it had been really, really well received. So kind of going beyond just the five to 30 minute practices every other week of the practice and medicine program was this immersion in an hour and a half, two hour elective that many medical students chose to take. So it was like, again, trying to be the change that I wanted to see and trying to change the culture of medicine so that we catch the trainees earlier on so that they have these, we always start off with like these tools to help them matriculate with health and wellness for themselves as they're caring for and as they're learning throughout their training. And then going into residency, I had worked with UCSC internal medicine residents on embedding some mindfulness workshops into their noon conference schedules. So there was an internal grant that I got to do like a pilot for using mindfulness as the foundation for a wellness program. And this was around the time when the ACGME had come down with the requirement that all training programs had to have some component of wellness. So it came at a timely moment. Is that still an active part of their curriculum or are they still practicing it or did that kind of drop off when you left? So there is still a wellness curriculum. It's not as heavily entrenched in mindfulness as the curriculum that I had introduced was. But UCSD luckily has a very robust center for mindfulness that is always constantly actively engaging in the medical school and trainee side of things. Yeah, and that's what it's all about, right? I mean, if we want to make this long term, the systemic type change, you know, these practices have to be built into the core curriculum at an early standpoint, right? Because it's truly an art. And before somebody can get to that point of that being able to practice this effectively in a 15, 20, 30 minute visit, you need to kind of refine your own craft. And you need to kind of be exposed to that are very year one in medical school, ideally even sooner than that. Because again, you're going to practice for yourself before you can try to teach somebody else or court somebody else down the road and to do it in a manner that's going to be successful and get them to buy in as well. So so yeah, I'm a huge fan of that and I'd love to see more programs try to incorporate that early on. The other thing that I remember again, you had talked about individuals with chronic lung disease, find it challenging to focus on their breath as an anchor, right? And so you need to kind of find other things. You were also part of this project. I think you were the PI that you is mindfulness based stress reduction for a chronic lung disease. Is that and I can't think of a better time than now that that would be more applicable. So I'd love to hear you talk a little bit more about that and then how would you relate that to COVID and especially this this case of long COVID that a lot of times we're seeing people not really bouncing back. There have a lot of other systemic issues as well, but particularly the pulmonary issues that comes with that. So the the study that you mentioned I presented at the American Therathsic Society and incidentally this was after I had recovered from cancer. So after after that I wanted to bring mindfulness more to the forefront of pulmonary medicine and this was one way was to entrench it with some research. And the data and I had very it was a very very small cohort of patients. I had like less than 10 patients undergo the mindfulness based stress reduction course. And the results interestingly showed in all of the different surveys, the questionnaires that we used. There was actually a trend towards interestingly the six minute walk distance actually being a little bit longer after they took the course which was like an unanticipated result. So that was one point thing. So like could it be that mindfulness helps you to accept and allow the shortness of breath that you feel. But that because of that acceptance it allows you to walk farther perhaps even faster longer. And then of course like the quality of life metrics definitely improved as well. The most poignant though of more recent work because I have taught it to my patients since that that pilot study has been that one of my asthma patients used to be riddled with panic attacks which would inevitably set off asthma symptoms. And she was in the middle of the grocery store and she wrote to me after the fact saying that because of the mindfulness training that she had she was able to get herself out of her panic attack like right then and there like she she paused, stood and did a brief body scan practice in the middle of the grocery store and that broke the cycle of that panic attack. And so to me it's like stuff like that the qualitative data that has been super poignant for seeing how people's stories with their chronic lung disease have changed with mindfulness. Let's go for it. Oh and just that with long COVID I think that integrative therapies are going to be the mainstay in terms of treatment for long COVID because those the effects of COVID go beyond that of the lungs in long COVID syndrome. There's a mental health component that also comes with long COVID, the ability, the chronic pain that some patients have also. So I think that mindfulness is going to be really key to the healing of long COVID as well. Right. Yeah. I was just going to say that's those are the stories that I love to hear and I think that when we talk about training and how do we how do we infiltrate the young minds of first year and second year med students you know as they go into clinicals. I was I was the chair of the integrative and complimentary medicine club at V Combergenia where I went to med school and you know I started this thing called meditation Mondays but it's just so hard to try to bring people to kind of come together ground your feet you know on the earth and are pretty long that we have there but it's things like that you mentioned and we did have you know topics on wellness and meditation why it's important but no one really points out those stories the data points as to how this works why this works right and I always talk about Dr. Andrew Heurman because he says these when when we understand the mechanism behind things that's when we start to take action. So you know it just hearing those stories are kind of the reasons how I got into this and why I really want to practice it as well so I just really wanted to share that. Yeah Neetang and you know you're talking a lot about mindfulness as an antidote right and I want to use so let's just pivot a little bit and I want to talk about something that's obviously that we need to talk a little bit more about it and draw pay more attention to in terms of what's going on over the last year or so I would say that you as a pulmonologist and a critical care doctor and a mindful next expert you are in a unique position to talk about this you know I can confidently say that no other stressor has affected us as a species on a global level in the past 30 years pretty confidently I can say that like this pandemic has particularly because of how long it's it's taken it's it's still going on it's been over a year now and we don't even remember what normal quote unquote is like right so how have you dealt with that the adverse effects you talked a little bit about long COVID and then the adverse effects and the complications particularly pain the dysautonomia those things is that you know how have you coached your patients and colleagues to deal with that and then the second question that I have and this one's a bit more challenging is this the racial tensions that have been going on in this country right the uptake of racism that we've seen over the last year year and a half and the brutality and those types of incidences and being at the the political climate has been very tense to say the least and you know I consider this particular topic and and these issues to you know I think that we can all agree that this is kind of the dark side of humanity right and we know that as healthcare providers that when we're stressed when we're tired the the worst of us comes out right sometimes we have a lack of empathy with our patients and and I have no doubt that the stresses from this pandemic have contributed to some of that the uptick in the dark side so the second part is that you know you being a Chinese American having you know an Asian American what has been your experience on the other side with respect to your ethnicity both as a physician sitting in front of patients who look at you as a Asian American and this virus and everything and then also as a member of society how has your life changed and you know what strategies can we use and how can we incorporate mindfulness to maybe not to be better to not let the dark side overtake us and not let our bad days define our character I think that second question could be like a whole nother podcast but let me answer your first question and very simply for the first question in terms of like how I bring in mindfulness and really like health and wellness into clinic visits with my patients who have heightened levels of stress as well as my healthcare professional colleagues is having them focus really on their five pillars of health like really coming back to the basics of health and wellness right like nutrition sleep stress reduction so stress reduction doesn't have to be mindfulness it has to be something that resonates with you that you'll actually do exercise and then social connection so not physical connection but social connection so that intentionality again comes into play with protecting time to connect with loved ones like zoom or on the phone so I've been really really highlighting the five pillars of health which is great because I'm an integrative medicine fellow at University Arizona so I feel like I'm practicing integrative medicine now way more than pre-COVID and so yeah it goes back to the five pillars of health so hopefully that answers your first question a second question about the anti-Asian racism that has increased dramatically over the last year unfortunately I have been on the receiving end of anti-Asian racism amongst my patients I'm gonna admit that and I I wrote about it in a Kevin MD article where basically a patient made a racist comment about China and I approached that experience in a mindful way but knowing very very well and feeling what an automatic stress reactivity response or a defensive response would have been so holding the duality of like the anger and the hurt that I was feeling labeling it and recognizing that so like noticing it with the mindful lens not trying to judge it because there was also this patient physician relationship that I didn't necessarily want to destroy I ended up in a place of curiosity so holding the anger and the frustration and the hurt of this particular statement and yet like responding with a question of genuine curiosity so curiosity is also one of like the main foundational practices within mindfulness I was able to kind of diffuse the situation a bit and come back into my own place of authenticity as a health care professional trying to come trying to provide compassionate care to this person who might not have had all of the facts or who might not have had the wherewithal to realize that I was Chinese American but not to like condone or to like resign or to accept that particular statement as being okay but more along the lines of feeling empowered in choosing my own response that was constructive as opposed to destructive so yeah in mindfulness I think mindfulness is a key to practicing being anti-racist and to also practice a self-compassionate response when one is on the receiving end of racism yeah right I think you know it's never oftentimes when we get that volatile you know attacks on us it's not it's not about us right it's it's about that person but like you said I think mindfulness can often help guide that compassion and empathy even with quote unquote our worst enemies and you know I I was listening to a Ted podcast at one point it was about Disney and you know they they they mentioned a common saying it's impossible to not fall in love with someone once you understand their story and I think mindfulness for me is you know when when I'm in a situation like yours which you know I I can't relate to that but when someone at least you know is angry at me and you know you can only control what you can control but it's about that curiosity that you just mentioned so on understanding why they feel that way right being authentic being genuine and you know it's it's evident throughout this podcast that you've had a lot of experience not only in healthcare not only with patients but just in life in general right with their cancer diagnosis and whatnot you've had a lot of opportunity you've had a lot of learnings you've also been a teacher and one thing I love learning about and other people is you know kind of their growth mindset kind of how they evolved as a human being can you touch on how has your philosophy changed if at all you know from when you first started mindfulness to where you are now yes so when I first started mindfulness the the attitude of non-striving was the hardest for me to embody and I think it's still a tough one for me especially being still entrenched in the practice of medicine but it's easier for me to be intentional about non-striving because I know what striving too much got me into like I dare say that had I not been as stressed out had I not been going 200 miles an hour had I not been doing and stressed out so much that maybe I wouldn't have had cancer so my mindset even from just the early training of becoming a mindfulness teacher has been I'm not in a rush necessarily anymore to like check off all the check boxes for like mindfulness credentialing and doing this training and doing that training and just consuming consuming and consuming so I'm very much more intentional about choosing additional courses to take when and with whom I'm teaching and who I teach to so there's this there's a bigger pause before action that has settled in over the last 10 years before it was much more of an urgency like I need to teach this I need to learn this I need to apply it and everyone needs to know about it and now it's more taking this non-striving lens of like there is no rush I am doing the work and people will come to do this work when they're ready like I can show everyone the door and I can be vulnerable and sharing my story so that they can see the door more easily but I can't open the door for them so similar to like what you were saying like really embodying and understanding that I cannot control the actions or the thoughts of other people I can only work on my own absolutely that's all we can do we can only work on you know control what you can control and acknowledge that what's not in in your control and be okay with that and so speaking of that you know we've been talking a lot about mindfulness and the hope is somebody will listen to this and and they're going to try to incorporate maybe if it's just a few breaths a day or just some of the strategies that you mentioned or how they can be mindful but speaking of that you know I think that most of us agree with we look at mindfulness as preventative care right for a lot of these ailments down the road and I think I heard you talk about this on your show is you know the analogy is it was or it's like brushing your teeth right you don't wait till you get the cavity to brush your teeth your brushing on a daily basis to prevent that category cavity excuse me but sometimes you do get that cavity right and sometimes that happens and maybe that's when mindfulness isn't going to be the solution or is it going to be the solution I'm not really sure and I'd love to hear your thoughts my thoughts are that you know it is more of a preventative care thing but often when you get to that point where again just using the metaphor you you get that cavity that that's when you need to go out and get some help perhaps it's seeking out a mental health professional or would you say that no mindfulness still has a role in that and individuals should still try to work through that themselves or where are you on that it is a combination and of course it's like a super person specific so I can use my own journey in cancer as an experience so going through therapy after the acute treatment that I had could not have been replaced with the practice of mindfulness so I wanted to just put it out there that I think mental health is tremendously important but that it was the practice of mindfulness that enabled me to get the most of the mental health care that I was getting and also give me additional tools for self-empowerment in changing the relationship that I had had with stress so it was kind of an injunctive treatment so I would say that mindfulness is not a panacea and there's actually contraindications to to learning mindfulness namely like acute suicidal ideation a psychosis very severe untreated anxiety and depression for instance the name of you but if using mindfulness doesn't necessarily get you to an end goal or an end result then that in it of itself is a practice opportunity to use mindfulness to perhaps again coming back to allowing and accepting reality just as it is even if you don't like it and not necessarily letting it be like well that mindfulness stuff didn't work for me this time so it's not gonna work for me in the future so mindfulness can then more so become a adjunctive skill that you learn that you then embody and then that aspect of mindfulness can then leak out into every nook and cranny of your life so hopefully that helps to answer the question so it's kind of like a combination of the two like absolutely when in doubt mental health about using mindfulness as an injunctive option can oftentimes be helpful especially if you partner with the mental health care professional to go through such an intensive program like mindfulness based rest reduction yeah absolutely you know I think all of us have trauma at least from childhood right that we need to learn to deal with and work through so even while we're doing mindfulness I think a lot of times these traumas pop up into our head now it's about figuring out how do we resolve these right conflict resolution but as well as the preventative side like you talked about now people listening to this podcast are gonna say hey how do I get started right so one thing I love to talk about our books and that's honestly how I kind of got started and you know Eckhart totally the power of now absolutely one of my favorite books about mindfulness and just being in that present moment and I had no idea Ron Epstein was your mentor because I actually read it tending which was fantastic and I think I talk about it almost in every episode so far that we recorded here and ultimately I was gonna test it which is why we were smiling in the beginning of this episode when you when you mentioned his name but any other read any other books you recommend or podcasts or websites and of course we have your podcast which will definitely you know link in the show notes and talk about yeah so full catastrophe living by John Kabatzen is basically the mindfulness based rest reduction course in a book so definitely highly recommend that um and then there is loving kindness the revolutionary art of happiness by Sharon Salzburg also a mindfulness and self-compassion contemporary that I consider one of my teachers I think all of us could use a little bit more self-compassion and then pertinent to the heightened racial tensions across our country is Professor Randa McGee's book the inner work of racial justice healing ourselves and transforming our communities through mindfulness for people who are interested in furthering anti-racism with mindfulness so those are some of the some of the books that I recommend I have a otherwise a long list as well I know that list keeps going growing and growing a dorshan I talk about this all the time we were just talking about it two days ago and then now he's got next a couple of books on them and so do I I think some of these are gonna have to skip the line here for me for sure just because I've enjoyed so much of this and you guys talked about Rana Epstein both of you guys so now I know two people are endorsing him so I gotta check his workout but Nietzscheing this has been awesome before we let you go we want to know two things working people find more about you your work and and then what's next for you what are you excited about what are some of your future goals coming up for you for the Mindful Heaters Collective and for your podcast what's coming up yeah so you can find me at my website at awakenbreath.org and you can also join the Mindful Healthcare Collective.com we also have the Facebook group by the same name we're at over 2100 members now very excited to have provided over 150 free online live sessions for healthcare professionals in the general public since March of last year the sister group of Mindfulhealingcollective.com is for the general public so same thing Facebook group and also as a website by that name and our podcast is the Mindfulheolarspodcast.com and you can find us on all major podcast platforms in terms of what's next so I'm currently teaching Mindful Space Stress Reduction and I will be teaching a cycle of Mindful Physicians my CME accredited course come August so it's really taking the application of mindfulness in two day-to-day practice of medicine and beyond and then Jesse Mahoney my my co-host for the podcast and I are going to be leading a retreat in the fall so we're looking for it to be CME accredited it's gonna be at a beautiful location stay tuned by following subscribing hope to see you there absolutely and we will again definitely for those you listening definitely check out the show notes we're gonna link everything we kind of just talk so one of the questions that we want to ask as Darish mentioned that you know our model here is adding that health back to healthcare so the last question that we ask every guest and we want to ask you is how do you think we can add the health back in healthcare or what is the term medicine redefined mean to you medicine redefined means embodying being willing and taking back the art of medicine into the healer's hands where healing the healers is automatically embedded into practicing the art of medicine I love that and I think that this conversation has given us a lot of perspective on how we can do that and hopefully people will follow you on your listen to your podcast I'm a huge fan both of you and your partner Jesse Mahoney and hopefully I encourage everybody to both join the either the mindful healers collective or the mindful healing collective I know I'm going to try to to do that myself and and be a part of it so you're saying I want to thank you so much for your time this has been awesome we've learned a lot and it's been a great conversation thank for your time you're welcome thanks for having me take care well I hope after listening to Dr. Liang you guys feel just as end out as I do please share this with anyone in your life that you believe needs to start on the practice of meditation and mindfulness and just being in the present moment in this beautiful life that we're all living one last thing before we go remember advice media don't forget to schedule a console with them to receive a $60 gift card and strategic insight on what your current digital marketing is doing or not doing for you contact advice media at drpodcastnetwork.com for slash advice media again that's drpodcastnetwork.com for slash advice media time for that quick disclaimer everything in this podcast is for educational purposes only it does not constitute the practice of medicine and we are not providing medical advice no physician patient relationship is formed and anything discussed in this podcast does not represent the views of our employers we recommend that you seek the guidance of your personal physician regarding any specific health related issues and until next time please subscribe share rate and review