By Lorenz Iannarone MD
“Super Doctor Syndrome” refers to a common condition afflicting a large percentage of physicians and other healthcare providers. Left untreated, it is known to lead to burnout. Dr. Iannorone’s biographical essay provides a classic example.
Do you know how “Storm Chasers” in Oklahoma get pumped just by getting into their high-tech machines and going out in search of tornadoes? Or how big game hunters get a rush of adrenaline in seeking “the big kill?” Sometimes I wonder if I just sought out stress for the same rush. People tell me that I’m at my best in a stressful situation. The more chaotic it is, the better and more efficiently I function––making quick decisions and “saving lives.”
I think we’re all stressed as soon as we shoot out of the womb. Bang! “Here I am, world!” Larry has entered the building. Or is it, “Where the hell am I? What am I doing here, and how am I going to get out of THIS predicament?”
It all starts with simple things like, “Would you like breast milk or bottled?” That sort of sounds like I’m in a restaurant––as if we even get a choice. Then comes school––of course, with competition. Then, more school, more competition; college, more competition. Then the stress of medical school, and making all those decisions about specialty and residency, and always more competition. Then finall—Ta Dah!––a JOB––with even more competition. Oh, and don’t forget about specialty boards, board certification, and then more school and recertification—and on and on and on.
And that doesn’t even include our personal lives. In my own, I’ve navigated a boatload of choices across an ocean of stress. But that’s another story for another article. Over the years I’ve traveled from the Continent of Childhood to the Land of Oh My God. It’s been awesome and terrifying all at once. My boat was sturdy, although it did spring some leaks on the sea of my life. Through the years, I was able to plug each hole and keep myself afloat, but at various times I did notice it was getting progressively harder and harder to see land. (Guess you figured out that I love boats and the sea).
By trade, I’m a General Surgeon, proud to call myself “One of the Last of the Gunslingers.” Able to leap tall buildings with a single bound. The person to call when no one else can figure it out, or if something simply needs to be done. But also, humble enough to just do mundane things like draining abscesses—or, what’s better than sliced bread: just taking care of people and making them better. Gall bladders, hernias, tumors, cancer. I take on all comers, and do my best to vanquish them out of existence; to make the patient “whole” again.
But through all that, and the mostly happy, years of my successful career, I have one nagging fear: the fear of doing harm to someone. To actually, but unintentionally, hurt someone—someone who looked up to me for healing. The first line of the Hippocratic oath, “First and foremost, physician, do no harm,” is perhaps the greatest stressor of my life. It’s my fear that somehow I won’t be able to live up to that oath. Stupid, huh? But that’s it. Forget the lawyers, lawsuits, the bureaucratic swamp, paperwork, EMR, long hours, and the emergency calls ripping you from sometimes peaceful, but often unrestful sleep. Forget forgetting to eat, or not calling your wife all day, or missing your son’s ballgame, your daughter’s first date, or the fact that your family should be your most important focus in life.
In 1974, Harry Chapin wrote the mindful song, “Cat’s in the Cradle.” The lyrics rang true for me, and I tried not to emulate the father who never had time for his child. But at times I knew I fell short—leaving the Hippocratic Oath lodged in the back of my mind like a dull drumbeat urging me on while persistently chasing me at the same time.
As a child I had wanted to be a priest, but when girls started swaying across my field of vision and affecting the limbic system in my brain, I knew that my vocation as a man of the cloth was doomed. Instead, medicine became the life and passion I became enslaved to. And I was good! Damn good! (and I still am). I even graduated second in my medical school class, got the residency of my choice, and found the job I wanted. But as my career took off, the stress intensified and it took its toll—slowly, steadily, lurking beneath the water’s surface. Through lost marriages and the death of a child, I powered on, revving up my engines to maximum RPMs to plow through the sea of stress. I even found my soulmate, my first mate to help me navigate the waters. She was the stability I had needed, and yet I wasn’t satisfied. I still needed to be the best, to reach my goal. And there it is . . . I can see it . . . It’s there . . . It’s . . . . . . .
BANG! It sure was there—right smack dab in the middle of my chest! Who’d a thunk it!? Are you kidding me? It was January 1st, 2013. I felt absolutely no stress. I was OFF. No call. Walking my dog. But there it was. “How can I get out of this predicament?” I frantically pondered. “Uh oh,” I thought to myself, “I can’t possibly tell my wife. She’ll go nuts. I’ll just tell her my blood pressure is up.” I thought I could beat this. But a Heart Attack?! Holy Crap! Could I actually beat a heart attack?! “Sure,” I told myself. “No sweat.” But, I was scared. Not of dying, but of not having done enough with my life. I would make amends. I would change my life. I would work less, take more time off, etc . . . You know, the usual. But that lasted a grand total of two weeks (or in my mind: two minutes). Regardless, I was soon back to my normal Energizer bunny routine, working sixty hour weeks 7 am to 8 pm. My wife was mad and afraid. She didn’t want to lose me, and I didn’t blame her. I didn’t want to LOSE me either!
Initially, I thought I (we) were on the right track, but very quickly it started unraveling. I was told I had bladder cancer, then another heart attack (the big one—95% occlusion of the LAD artery—THE WIDOWMAKER!). Then prostate cancer, then bladder cancer, AGAIN! Damn! This felt just like school—competition, school—competition all over again. “God,” I thought to myself, “I hope I don’t have to go through the equivalent of medical school and residency again.” In the scramble of my mind I asked myself, “Who am I? Where am I? What am I doing here?” The thoughts were haunting, relentless. Was I about to finally reach my goal?
Have you guessed what it was? BURNOUT! Yep, that was it. For years, I had whipped myself up into a frenzy to be the best, to not make mistakes, to be perfect, with the false goal that I was in it to SAVE LIVES. A noble and lofty goal. The most admirable of professions. But was I doing it to help people, or just to satisfy my own selfish ego? Ah, that was an important question.
Not only is the first dictum of the Hippocratic Oath essential, but we cannot and should not ever forget another little tidbit of philosophy buried in the treasure chest of medical wisdom: “Physician, heal thyself.”
I can thank my wife for opening up that treasure chest and finding some truly valuable “pieces of eight.”
From my earliest days as a surgeon, I learned that “to cut is to cure.” That’s mostly true, and I am faithful to that motto. Accordingly, my favorite conference is the Trauma Conference in Las Vegas, which I try to attend every other year. Although my wife loves Vegas (even if she won’t admit it until we get there), she had been on the lookout for a CME course that was a little more calming, or at least not as stressful—especially in this horrific time of meaningless violence.
In early 2016, she found an autumn event in the Berkshire Mountains that promised a curriculum of Yoga as a science and meditation to help physicians skillfully deal with burnout. The conference, presented by The American Meditation Institute, was held FOR physicians and other health care professionals, and it awarded 30 CME credits. Can you believe it? 30 CMEs! Almost as much as the Trauma Conference in Vegas. And meals were included!
Yup, breakfast, lunch and dinner. The only hooker was that there wouldn’t be any meat served. When I called the reservation line, the receptionist assured me that the food was delicious. But I was skeptical. “What,” I groaned in disbelief, “You ain’t got NO meat?! Do you at least have fish or lamb?” “No,” she politely replied, and then went on to explain that, “The vegetarian cuisine was included as part of the program’s de-stress techniques.” Then she went on to assure me that if I had special needs that required red meat, they would be happy to accommodate my needs. My needs? I could picture myself in the midst of about a hundred people all eating tofu and vegetables and quinoa, while I’m slicing down a nice medium rare piece of New York Strip! Doubting that would look good, I gulped and said, “Thank you. I’ll let you know if I have any demands for a succulent, melt in your mouth . . .” But I digress.
Having set aside my distaste for a vegetarian meal; wait, hell no, this was to be a vegetarian week! Not one meal, but 15, or maybe even 20. Plus snacks—all vegetarian snacks! Could I do It? Of course I could. I weathered medical school, residency, the EMR, 2 heart attacks and multiple cancers. I could weather a week of vegetables. So I calmly returned to reading through the conference syllabus and I thought, “This doesn’t look bad.” After all, my wife has never steered me wrong before, and she’s always been The Navigator between us, so I said, “What the hell, let’s go.” And that’s when my life changed.
Before I get to “my life as a yogi,” remember when I told you that I had wanted to be a priest way back when I was in Childhood Land. Well, my belief in God, although it may have ebbed and flowed somewhat over the years, has never completely faded away. If you have ever had the awesome experience of being in an isolated spot and looking up at the night sky, transfixed by the millions and millions of stars that were configured for your delight, you can’t help but believe that we are not all there is. We are not the be all and end all of everything. No matter what you believe, your eyes on that night did not deceive you. There is indeed something greater than all of us. It’s out there. It surrounds us. It is God, by whatever name you call Him, Her, or IT.
Around the same time a colleague of mine who was in the process of converting to Catholicism grew increasingly concerned about the sacrament of confession. Knowing I had once considered becoming a priest, he asked what I did; how I confessed. I told him that on certain nights after work, I went out into the garage with a cigar and some Jack Daniels, and I talked to God. It was quiet, away from everything, and I just talked, mostly in my mind, not out loud. (Some people, my wife included, would think you were crazy if they caught you talking out loud to yourself). I would reflect, “Boy, did I screw up today,” or, “I really did some good today.” Whatever. It doesn’t matter. The reflection was enough. He heard me. And I cut out the “middle man.” I vow to do better, and I try. I really do try! Maybe the church would frown on my method, but it works for me. My colleague must have heeded my advice, as he did become a Catholic. Little did I know until I went to the AMI conference, but I was already starting on my journey to healing through meditation, contemplation and self-awareness.
On Becoming a Yoga Scientist
My wife and I were off to a great adventure in the Berkshires. As we left civilization and headed north, the sometimes turbulent waters of “doctordom” smoothed out into oceans of golden yellows, brilliant oranges and fiery reds—filling the hills and mountains with the sea of autumn. I was in awe. I felt my muscles and mind relax. It was evident that God was here. And even if He weren’t ‘exactly’ here, I knew that He was close by. As we neared the resort, I was totally relaxed. Maybe I didn’t need meditation at all. Maybe all I needed was an occasional drive in God’s country. Boy was I in for a surprise.
After we unpacked, we explored the scene—preparing for my last night of unbridled gluttony. Now, I would soon learn through the teachings of Ayurveda, that my body constitution is a pitta/vata. Well, that may be so, I thought to myself, but I’m also an Italian/Austrian! So I am partial to pasta and pastry. Therefore, we soon found ourselves in a quaint little Italian restaurant, sipping a lovely Tuscan red Montepulciano, and feasting on veal and gnocchi—with profiteroles and espresso for dessert. Feeling satiated and exhausted we fell into a fitful sleep ready to face whatever awaited us the following morning.
I was not disappointed. As announced in the brochure, vegetarian delights abounded at the breakfast table. We chatted and got to know a few people, but by the end of the conference everyone knew everyone else. There were many specialties represented at the conference, ranging from ER physicians and Primary Care, to psychologists and psychiatrists, and paramedical professionals. Oh, and one general surgeon. Boy, did I feel like a fish out of water! But as Leonard began speaking, I found myself mesmerized by his “aura.” As the founder and director of AMI, he obviously was the central figure at the conference, although all the other lecturers were just as knowledgeable and engaging. Leonard, however, stood out to me as—well, I can only describe him as a “gentle soul,” someone to listen to and learn from. An individual with a significant amount of insight. And while I may not agree with every view, he certainly made me think and become more Self-aware. Every day he led us through the guided meditation practice. Although I was just a novice, I must admit I was able to go deeper each time. On the third morning, however, something important happened. Before class I had taken my normal blood pressure meds, eaten a substantial breakfast and was into the normal routine when the entire group began to meditate. I was OK at the beginning, but as we were into it for about 5 minutes, I started to get dizzy and almost passed out. I was able to continue, but afterward I took my pulse and found that it had dropped by 20 beats per minute. I’m sure my blood pressure had done the same. Wow! This really does work.
As we began our journey into meditation, we were given the opportunity to select our own mantra. Since I was once going to be a priest, of course I picked my Hero’s name as my mantra. And I felt confident I was making progress. Slowly, slowly as I practiced more and more I began to recognize what Leonard referred to as our shared Essential Nature of consciousness-wisdom-bliss (in Sanskrit known as Sat-Chit-Ananda). But what really brought this teaching home to me was learning that the highest principle of Yoga, ahimsa, meant “do no harm, injury or violence.” Ahimsa is compassion, and is inspired by the premise that to harm another is to harm oneself. Wow, the Hippocratic Oath. They didn’t teach that yogic connection in medical school. And I thought Hippocrates was Greek. It turns out he was a Yoga scientist! Go figure. By the end of the conference I learned so many practical techniques, I realized that to truly benefit from it all I’d have to incorporate the teachings and apply the tools into my personal life and surgical practice. And that’s exactly what I did!
After we came home, I continued with the AMI MEDITATION and diaphragmatic breathing practices for myself and my patients. Initially, I wasn’t as faithful as I would have liked to have been personally, and I am still working on that. But I’d like to share with you two experiences I had at the hospital that were very mind opening to me.
Meditation-in-Action
Several months after the conference, we were in the operating room doing a very difficult gall bladder. The gall bladder was so inflamed and fibrotic that we had to convert from a laparoscopic to an open procedure, and even in doing this, the tissues were rock hard and friable at the same time. And there was a lot of bleeding—not torrential—but annoying. Even though we were dissecting slowly and meticulously, as fate would have it, with one small maneuver, we were suddenly in a bloodbath. I had nicked the hepatic artery. We hadn’t been able to see it due to the fibrosis, and it couldn’t be avoided. But regardless, I had done it, and my stress level went through the roof. It was a terrible feeling, and what was worse, blood was pulsing up into my face, covering my mask and glasses so I couldn’t see. No matter how the nurse tried, she could not get me cleaned up enough to secure the bleeder. I had no choice but to leave the OR and clean up, or else I would have contaminated the wound, making matters even worse.
The anesthesiologist was preparing to transfuse the patient, so I placed my assistant’s finger directly on the bleeding site, totally controlling it. Then I went to wash and change. While out of the OR, I began to contemplate to myself, “How do I get out of this one?” Then, intuition spontaneously dawned! I closed my eyes, stood at the sink and silently listened to my mantra for about sixty seconds. As the mind slowed down, I noticed I was breathing diaphragmatically and that fearful thoughts were no longer disturbing my consciousness. Then, without even thinking about anything other than what was to be done, I rescrubbed, reentered the OR, identified and stopped the bleeding with one stitch, and completed the procedure. Three days later, the patient went home. I was a “hero” once again. But this time something was different. I knew the success was because of something other than “me.”
Many months later, about three weeks before AMI’s 2017 conference, I found myself in another precarious situation. I had been consulted to see a middle-aged, but chronically ill patient with a small bowel obstruction. She was a cardiac transplant patient awaiting a lung transplant. She was on continuous oxygen therapy and a slew of medicines including immunosuppressive therapy so she wouldn’t reject her new heart. But now she was here, and I was in charge. She was on the medical floor, and even though the nurses and staff were doing their best, what could go wrong, did go wrong. Because she had been in and out of the hospital for years, her veins were sclerosed resulting in no venous access. The nurses could not get blood. They could not even start an IV. The patient was anxious, hyperventilating, hypotensive and tachycardic. I knew I needed to get her hydrated; to place a nasogastric tube to decompress her massively distended stomach in order to avoid an operation. In addition, she was on anticoagulation therapy, and her labs done earlier were significantly abnormal. Every needle stick caused bleeding, and placing a nasogastric tube does carry some risk—especially if the patient is anticoagulated.
Well, the placement seemed to go fine, and I advanced the tube into the stomach—only to be met with significant fresh bleeding. Either she had an ulcer that was bleeding (which I doubted), or had I done something? Had I torn the tissues in her nasal passage? Had I perforated her esophagus or stomach? She had been vomiting earlier and there was no blood. Whatever it was, I had done it! Stress Level—one million! I was filled with intense anxiety and fear.
Immediately an old memory flashed into my mind. About thirty years before, I was asked to see an equally critical patient, together with another specialist. As my colleague walked out of the patient’s room, he observed, “This patient is really sick. Let’s see what Dr. Iannarone can do.”
Well, that’s how I felt now. Better call Dr. Iannarone. Oh, wait, I’m Dr. Iannarone! My heart sank down into my Muladhara Chakra at the base of the spine. Things were going south, and I was captain of the ship. Anxiously, as I began lavaging the blood from the stomach, I looked around at the organized chaos. I knew that everyone was looking to me for guidance and leadership. Then without thinking, as everyone was doing their job, I closed my eyes, and began listening to my mantra with one-pointed attention. In the process I vanquished my unhealthy thoughts and emotions of fear and anxiety (preyas). I didn’t have the luxury of a lengthy meditation, only about 20 seconds. Regardless, it was enough. As soon as the practice ended, I knew exactly what I had to do.
Now calm, cool and collected, I announced, “We’re moving to the ICU. Now!” Then I started barking out orders, taking control of the situation. I’m pleased to report that the patient did fine. I was able to get IV access, the bleeding stopped, and x-rays revealed no significant injury. The tube started draining intestinal contents as it was supposed to, and the patient stabilized. Success!
I realized at that moment, that we really are all connected. As others have already observed, “We are ‘one.’” The patient was terrified and could sense my anxiety and fear, heightening her terror at what was happening, and of what might have happened. She could sense my feelings, and as soon as I relaxed and calmly took control, her anxiety and fear also dissipated, and she began to believe everything would be alright.
Certainly, anyone can say that these two events were simply mind over matter. And I would agree: meditation is mind over matter. But there was more to it than meets the eye. As a Yoga scientist I now have practical tools that enable me to be more skillful. In the face of fear, anxiety and stress I can now calm my mind just by focusing my attention on my mantra and breath. And I have trust from personal experience that the mind’s conscience (buddhi) can masterfully advise me what to do and what not to do in every situation. These tools, coupled with my education, training and experience as a physician, made it possible for Dr. Lorenz Iannarone to navigate through these kinds of challenging, almost no-win scenarios, while decreasing my stress levels.
I also brought back some gifts from the AMI conference for my patients, and already diaphragmatic breathing exercises are showing real promise for me as a surgeon. After I returned to my medical practice, I began having my patients close their eyes, and concentrate on slow, deep, diaphragmatic breathing while letting go of any uninvited thoughts, images or sounds. Some questioned, “This is meditation?” And to that I was able to tell them from my own personal experience, “Yes.” Oh, by the way, so far I’m seeing a positive response from most of my patients.
I was so impressed with AMI’s 2016 conference, Leonard Perlmutter, and all of the faculty, that we decided to return in the fall of 2017. Not surprisingly, the second time through the CME curriculum reinforced what I had learned, and although I am still a novice, my practice of AMI MEDITATION has deepened and I am personally growing more each day. I now am prepping my patients in the office preoperatively, teaching them the breathing exercises, and I’m already seeing a decrease in the use of opioids in a good proportion of patients. It is difficult to do a double blind prospective study, as we can do the same operation on 10 different people and see 10 different postoperative responses to pain and usage of pain meds. But in the majority of patients, I do see a positive response—most of them telling me that they are decreasing the frequency and strength of the narcotics. They are doing this by using these techniques to relax their muscles and mind, and thereby decrease the reaction to the pain—rather than simply reaching for a bottle of pills.
I really am still new at this, but I am gaining more insight day by day. When I feel stressed during the day, instead of screaming out my Hero’s name in a fit of anxiety, stress or frustration, I simply close my eyes, and focus on my mantra. I acknowledge my fear, anxiety and stress and willingly offer it into the fire burning in my heart center. I am not walking around the operating room and hospital doing alternate nostril breathing, but I am closing my eyes and doing my deep diaphragmatic breathing exercises in between cases, after seeing a difficult patient, or just to relax. And it is working! Not one hundred percent of the time, but in a significant portion of my days. And now my stress level is at a more acceptable level. And who knows, maybe soon I won’t even need my Jack Daniels.
Lorenz Iannarone, MD is a graduate of Temple University School of Medicine, and has been in private practice at Holy Redeemer in Meadowbrook, PA for over 30 years. Currently he serves as Chief of General Surgery, and is an Assistant Clinical Professor of Surgery at the University of Pennsylvania teaching residents.