Swimming Lessons for the Greater Good

By Ajeya Joshi, MD and Venkat Srinivasan, MD

These are incredible times, putting it mildly.  Not only hospitalists and intensivists fighting the ongoing epidemic in the trenches, but, every one of us has been affected–socially, financially, morally, ethically. It doesn’t matter whether we are in academic medicine or private practice, a trainee looking to start her first job, or a seasoned practitioner. Unsettling questions were raised during this past year of COVID-19:  existential threats to practice viability with declining revenue and ongoing overhead, possible decimation of investment portfolios and nest eggs, mounting debt and imminent repayment deadlines, clinical inactivity and the guilt of having to let go of loyal staff.  Not to mention the new rules for social engagement, the loss of simple pleasures in our lives like vacations, eating out, recitals, and road trips.

The core of who we are as professionals, family members, citizens and individuals has been threatened.  Add to this that the great uncertainty – of how long, how bad and most importantly, if we or our loved ones would make it through this crisis alive– looms over everything we do.  Compounding this is the realization that for the very first time in a long time, we are not in control.

In reality, we never were truly in control. Were it not for this pandemic and its accompanying worries, we would still be worried about the imperfect surgical outcome, the post-operative stroke our patient sustained, the prospect of academic promotion, the rising overhead and decreasing reimbursements, and so on.  Tack on to these concerns global uncertainties, market fluctuations, post-election unrest, societal attitudes, and even family behavior as anyone who has had a teenager at home would attest to.

It is crucial then, in this moment, to recognize and accept that stressors big and small will be an ongoing presence in our lives.  We learned in medical school about the proverbial saber-toothed tiger that represented a threat thousands of years ago, and the way our body would react.  The sympathetic system goes into overdrive and we mobilize energy and activate muscles through the HPA  (hypothalamus-pituitary-adrenal) system and adrenergic systems.  Parasympathetic systems like digestion and sex drive shut down. We get ready to fight or flee, as succinctly described by Walter Cannon, whatever promotes survival.

It’s still important to generate this stress response, although these days that tiger is figurative and not literal.  However, the inability to turn it off, a problem many of us have, is destructive and dangerous.  Persistent cortisol and other biochemical stress mediators in our bodies lead to adverse mental and physical consequences:  decreased immunity, impaired glucose metabolism, and fatigue, among others.

The stress response, however, is an internal reaction over which we can gain control, and by choosing and emphasizing constructive measures for self-care, we can regulate it effectively.  These measures include resiliency building to counter stress and its harmful effects, and other aspects of healthy living.  Doing so will help us physicians as individuals to endure this crisis without feeling beaten or broken, and by extension will help us to be optimally helpful to our families, patients, and community.  We can do it, and we and those around us will be better off as a result!

Salutogenesis (Aaron Antonovsky) is a concept unlike the traditional pathogenic medical model separating health and illness.  The pathogenic model, to use an analogy, views the riverbank as ‘health’, and preventive care attempts to keep us on the riverbank. Illness is falling in the river, at which point health care team members jump in to save us and pull us back onto the riverbank (cardiac catheterization, gallbladder removal, additional cholesterol medicine prescribed).  However, a more accurate notion is that life’s stressors amount to our constantly being in the river.  The only issues are how deep is the river and how well can we swim. Salutogenesis calls for better coaching/training so we can swim more effectively.

Swimming more effectively amounts to building resiliency and emphasizing self-care principles.  Augmenting resiliency is entirely achievable, no matter what our age, background, assumptions, prior habits, or seniority in the medical profession.  The need is for consistent and concerted efforts to gain an enhanced state of physical and mental health equipping us to better cope and thrive in the face of life’s inevitable stressors.

Let us not forget the principles that we have known and have been taught by our grandparents and our teachers. A healthy diet, appropriate exercise and adequate sleep are indeed cornerstones of health. On top of these, science has also proven the effectiveness of various other modalities. Optimism, humor, companionship and the arts can all nudge us towards the healthier end of the spectrum.

The relaxation response was discovered Dr. Herbert Benson, decades later but in the same lab at Harvard Medical School as Walter Cannon.  The relaxation response is a process of profound physical and mental calming changes invoked by a deliberate, intentional practice.  Whether it be meditation, yoga, or another mindfulness practice, abundant literature in the field of Mind-Body Medicine (MBM) documents healthy behavioral, biochemical, anatomic and epigenetic improvements in those learning and implementing the relaxation response. Irrespective of the method adopted being spiritual or secular, the relaxation response has been scientifically proven to be effective and reproducible.  It can be learnt in person from a preceptor or through online apps.

Let us swim, not sink. We can. We must. If we need a coach, let us seek one.

Ajeya Joshi, MD is board certified through ABOS, and a diplomate of the American Board of Lifestyle Medicine.  He is in practice as an orthopedic spine surgeon at South Texas Spinal Clinic in San Antonio, TX.

Venkat Srinivasan, MD is board certified through the American Board of Internal Medicine, and a diplomate of the American Board of Lifestyle Medicine. He is a certified trainer of the SMART (Stress Management and Resiliency Training) Program), and has written a book on Mind-Body Medicine. He delivers primary care using Lifestyle Medicine principles at Hill Country Lifestyle Medicine Center.