The following content has been reposted with the permission of Dr. Neha Sangwan. It was originally published on her website, here.
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Kim: Dr. Neha Sangwan is an internal medicine physician who drove herself to burnout and thus became something of an evangelist for dealing with stress. She’s the CEO and the founder of Intuitive Intelligence—that’s the name of the company, rather than the trait itself—and an international speaker who teaches people to read their own body signals and to communicate. Dr. Sangwan is here to speak at the World Women 2017 Conference in Auckland [New Zealand]. Good morning!
Doctor Neha: Good morning, Kim! So honored to be here.
Kim: So honored to have you. Do you not get stressed anymore?
Doctor Neha: That is probably the biggest story people make up: Since I teach communication and understand the biological origins of stress, that somehow means I am no longer human.
Kim: Let’s talk about why mental stress causes such apparently dire physical effects, which I think it does. It causes heart attacks; it causes diabetes; it causes obesity apparently. Why?
Doctor Neha: Research shows that more than 90 to 95 percent of disease is either caused or exacerbated by stress. In the past, traditionally, we have thought of physical health is when we say “health.” The most interesting thing that I figured out over the years I sat at the bedside with patients is that if I asked them the right questions, we could actually get to the root of their stress. Their answers were often like, “Dr. Sangwan, I’m just in a work environment that is toxic. I’m in a relationship that has long since expired and I don’t know how to get out.” They would tell me these things if I actually sat down and had a conversation to ask some real questions.
Kim: What is the connection between mental stress and ill physical health?
Doctor Neha: I would say it’s even more than mental. I’d say it’s mental, emotional, social, financial. Many aspects of our lives can cause stress. When the body is under stress, it compromises your immune system. When I am very stressed out, say financially, I find myself up at night and then I’m going to the doctor asking for pills for insomnia. The importance of sleep is that’s the time when the immune system has a chance to repair. That’s the time when the body gets to heal itself. I’m giving you a very simple example, but when you undermine your immune system through stress, all sorts of outcomes keep the body from healing itself. The immune system is the body’s main defense against disease.
Kim: Sleeping pills would be a good thing then?
Doctor Neha: I am not against sleeping pills. I just want to make sure that they are used to bridge people short term through whatever it is that they’re going through physically. If they need some sleeping pills to get through the experience that stress is causing, that is great. Use it as a short-term bridge. I also am hoping that people will use what I call double vision, which is then asking themselves, “What’s at the root of my stress, and how can I resolve this long-term so I don’t have to continue to use short-term treatment over and over, pretending it’s a long-term solution?” The best way I can say this is that your headache is not an Advil deficiency.
Kim: When we talk about having anxiety or an anxiety syndrome, do you think what we mean is just stress? Or is that something different?
Doctor Neha: I would characterize anxiety as a specific type of stress based in fear. On my way here I was listening to your previous guest talking about anger, anxiety, sadness, fear … Fear is the main emotion around anxiety. The way I refer to anxiety is it’s a failed attempt to try to control the future.
Kim: Is it your experience that you can change your stress levels by changing your lifestyle or simply by changing your attitude toward your lifestyle?
Doctor Neha: Absolutely. That’s a huge component. I’ll give you a simple example on lifestyle. I mentally used to feel that I was more important in the world the busier I was. The more engagements I had, the more I was flying … I felt a sense of importance.
Kim: That’s good, right? Because if you don’t feel important, you might be stressed about it.
Doctor Neha: It depends on where your importance comes from. Do I source it from the outside world and what society tells me is important? Or do I go inward and ask myself what I value and how I feel inside? How is my body communicating with me? There are different ways you can decide. For me, I want to have great impact in the world, but as you mentioned, I wanted so badly to please the world and be that important doctor who saved the world, that I was willing to burn out. That’s when I’m out of balance, and that’s where we can go back to what I said earlier about double vision. [Think about driving as an example] When I’m driving a car, I have to pay attention to whether there’s gas in the car, what the speedometer says, whether the “Check Engine” light is on, as well as the external world and the conditions, such as whether someone’s passing me on the right, whether I need to make a left turn. I call that double vision. As our world gets busier and busier, and faster and faster, I actually would not say faster is always better.
Kim: Is this a female trait, the need to please people?
Doctor Neha: When we are developing as females, there’s a hormone called oxytocin that has that nurturing, mothering, belonging side to it. The need to belong—everybody has that but to different degrees. Men grow up with a form when they’re young, and with testosterone they get more of the hunter-gatherer side. Do I think that we women are more communal? We may be, and we may have that sense of taking care of not only ourselves, but also belonging in community more. I wouldn’t say that there’s a clear yes and no to that kind of question.
Kim: You’re on dangerous ground with that, right? What you’re saying is that women are possibly more at risk of burnout?
Doctor Neha: Okay, I can definitely see your point.
Kim: Just following a line through to its logical conclusion here.
Doctor Neha: I hear you. I actually agree with what you’re saying. I could see how that would be one perspective on it. What I was more trying to convey—I don’t believe that it’s easier for women to burnout—was more of how we strategically respond to stress. Even if we are more communal, that way of leadership would cause less stress in the sense that you’re leveraging other people rather than doing it all on your own. Would that make sense?
Kim: Yeah.
Doctor Neha: I don’t think I would put all women in one category, and all men in another. But if our sense of belonging, the need to belong, and where we focus our attention is not balanced, over time it can definitely lead to burnout.
Kim: What did your burnout look like?
Doctor Neha: Oh, Kim, It is so vivid to me, even now. It was 13 years ago. I was a physician working in the hospital. I had studied all these years. I was hundreds of thousands of dollars in debt. Just moved to a new city, wanted to buy a home and start my life, and I felt the need to please this new organization. If I did a great job, I became a partner and I would be tenured in for life. I wanted to do a great job, so I volunteered any time I could. I was single and didn’t have kids. Anytime they were short-staffed, I would say, “Oh, I’ll help.” My desire was to be a team player, to show that I was willing to do the work to become a partner. In that endeavor, in that quest, I found myself using Mountain Dew and—
Kim: No, not Mountain Dew!
Doctor Neha: Yes! Sugar!
Kim: Oh my God, did you come back from that?
Doctor Neha: Now, when I think back, it makes me sick to think about what I did to my body. Sugar and caffeine were the strategy I used. What I’d say to anyone listening is every one of us under stress has an equation that we know gets us through those stressful times. What is yours? Mine was two 16-ounce Mountain Dews plus a king-sized Snickers bar, and you could get me through 36 hours of taking care of other people.
Kim: Wow! What happened apart from a breakout in your complexion? Did you start crying inappropriately? What?
Doctor Neha: I was actually in the middle of seeing patients that day, and I had kept getting phone calls as new admissions were coming in. I walked up to a nurse and said to her, “Could you make sure the patient in room 636 gets 40 milliequivalents of potassium?”
She had known me for three years, and she looked at me and said, “Dr. Sangwan, are you okay?”
I said, “Why are you saying that?”
She said, “This is the fourth time you’ve asked me that question.” That’s how tuned out I was. It took someone else telling me that to realize that I was not effective. That’s burnout—a triad of ineffectiveness, cynicism and exhaustion. I get so exhausted that I start getting cynical in my job, and then suddenly I realize I’m ineffective. That’s when you’ve gone all the way down to full burnout.
Kim: Apart from going cold turkey on the Mountain Dew, what did you do?
Doctor Neha: I went into the bathroom and called a colleague, so no one else could hear me.
“Can I come and see you? How soon can I see you?”
He said, “How about tonight at 5 o’clock?”
“How about right now?” That was the moment that I got it.
“Absolutely, come right over.”
I did multiple things. The first is he put me on medical leave. I spent three weeks slowing down rather than running like a chicken with my head cut off. But when I slowed down, the hardest part was being with my own judgments of myself. You failed, you didn’t do a good job, what are other people going to think of you … The interesting thing was that I was more worried what other people were going to think of me than what I thought of me. Slowing down and working with my colleague helped me start to nurture myself and take classes learning about the mind-body connection, nutrition, sleeping—all these things that healthcare really hadn’t taught me. They had taught me how to, in spite of myself, make sure I could, for extended times, take care of others.
When I came back, I started a program called Self-Care and Health Care. I wanted to help heal the healers as my next endeavor. When I was at home, I ended up going outside, being in nature, and doing so many things that healed me. I wrote in my journal. I spoke to people who were kind and loving to me. My family was incredibly supportive. I was working with this colleague weekly, and he was helping me realize that my own mental attitude—my belief that I didn’t need to be in the equation—had also contributed to what had happened. I became aware of personal accountability, as well as understanding the pressure cooker nature of circumstances I was in.
Kim: Was it the tremendously hard work in itself that led to the burnout, or was it your attitude toward it? In other words, if you carried that same workload now, would you do it better? Or would you not do it?
Doctor Neha: I would tell you yes. If I did it, I would speak up more. I would do it differently. I have now moved into different work that I feel is more integrated and comprehensive in the definition of health.
Kim: Plus, you’re working for yourself, which I imagine not everybody can do that.
Doctor Neha: My belief is that people can [work for themselves]. It’s about getting really clear and being willing to listen to your own heart slightly louder than you can hear the voices of others.
Kim: I meant to ask you about that. I’ve heard you say this, “To reach your highest potential, you have to be able to hear the voice of your own heart louder than you can hear the voices of others.” Does that not make you selfish?
Doctor Neha: That’s a great question. I don’t want you to tune out the voices of others. Giving and receiving feedback in the world is very necessary and important. I also think that my first responsibility when my heart starts racing and my stomach starts turning is to tune into my body. If I don’t tune in to myself and know what those signals are telling me, then I won’t know how to act. I won’t know what the next question is to ask. I won’t know what the next decision is to make. I won’t know what to do in the greater world if I am not self-managing.
Kim: One could listen to oneself all day, but one isn’t always talking sense, right? Do you know what I mean?
Doctor Neha: Absolutely. You’re right. The way I think of it is that there’s me, we and then the world (to simplify it greatly). We are all moving in those three realms continually. In the next book I’m writing, I actually call it triple vision, not double vision. Yes, I do have to pay attention to what is happening for me (how much energy do I have, what do I value, what’s the right next step for me), while I’m talking to you and connecting to you and everybody else. When I’m aware of those three pieces, I can navigate the world in a way that’s authentic, that’s aligned, that’s me, and that’s connected.
Kim: Talking about the health impacts of stress, do you think that there are many unnecessary treatments and interventions? I’ve just been reading an article, for example, about how easily people say, “Oh, we’re going to give you an operation, put a stent in,” but stents for stable angina patients are of no benefit. In fact, there would be far more benefits in telling them to do lifestyle changes or even just go on the meds … Is that too much intervention. Do you think that stress is leading people to seek intervention or unnecessary treatment?
Doctor Neha: As a physician what I wanted most was to be able to help people. In my schooling, what I was taught were medications and interventions. Either you get an operation, get a stent, or a drug. That’s what I knew. Until my own burnout, I did not understand the whole world that was out there to help people with stress. My short answer for you is yes; there are a lot more interventions that are happening than probably should be. What I would say, though, the physicians are giving you the options that are in the physical world for an immediate fix. Each patient gets to decide if that option seems right for them. Yes, can we have people make lifestyle changes, and does that make a difference? Yes, it’s been proven in research absolutely. The problem is, a lot of times, a) physicians don’t feel like they have the time to go down that road and b) we actually don’t know how to inspire and engage personal accountability with someone when they’re not in the doctor’s office.
That’s the trillion-dollar question in healthcare: What if we could use that sacred time we have with patients at that moment they are afraid? When they have a diagnosis that they didn’t have before, or they’ve had a heart attack or a stroke. What if we used that sacred moment very carefully, and we partnered with them to inspire and engage them in their own health, and really help them down that path? That’s what’s really opening up in the world now.
Kim: How would you do that?
Doctor Neha: I was a hospitalist. That meant, if you had a heart attack or a stroke and you came in the hospital, I’m the one who carried you through your hospital stay until discharge, and then I’d send you back to your regular doctor. My personal flavor of [engaging patients in their own health] was that once I had stabilized them physically, then the night before discharge I would say to them, “How interested are you in not meeting me here again? I would be happy to see you at the movies or the theater, but how interested are you in not meeting me here?” They’d all say, “Absolutely interested.” I’d say, “Great. The nurse is going to bring you paper and a pen. If you want to answer these five questions tonight, if you want to write about them and journal about them, in the morning I’ll give you an extra 15 minutes of my time so that you and I together can figure out the source of your stress, what resources you need, and how we can make sure this doesn’t happen again.” I call the questions The Awareness Prescription. It evolved over time as I was in the hospital.
There were five questions. The first one is “Why this?” Why did this part of your body break down? Why a heart attack? Why not something else? Why not your liver, or why not your stomach? Why is this part of your body breaking down?
Kim: Did they usually have an answer to that?
Doctor Neha: Yeah, they really surprised me. They got it. They would say—
Kim: They don’t say, “You’re the freaking doctor!”
Doctor Neha: The good news is I am the doctor! That’s why we got you physically stable. Now, what I’m trying to do is help them realize that they’re all interconnected to the other aspects of their world.
I’d say, “Why this? Why this part of your body?”
The second question is, “Why now?” Why not three years ago? Why not two weeks from now? Why did your body need to get your attention in this moment? What’s important that you needed to get? What’s the message?
The third question is, “Since hindsight’s often 20/20, what signals might you have missed along the way that you can see now?”
The fourth question is, “What else in your life needs to be healed when you leave here?”
The fifth question was, “If you spoke from the heart, what would you say to me?”
Kim: What do they usually say to that last question?
Doctor Neha: Often, they would tear up. The main piece of that was they said that I gave them permission to say the truth. Sometimes, they’d say, “I’ve not spoken to my son in 20 years. We got in a fight, and it has weighed on my heart heavily ever since.” I had a Vietnam vet say to me, “I’ve never spoken about Vietnam, and I thought I could lock it away. It is clear to me that that is why I just had a heart attack.”
Kim: Do you think that there may also be clear physical issues to deal with, but that whole process of questions enables people to join some dots for themselves that they’ve never needed to do or been forced to do before?
Doctor Neha: Absolutely. I believe in the and. I believe that there are physical aspects that need to be handled and taken care of. When someone comes in the hospital, that’s my first and foremost job.
Kim: The danger is, I suppose, that you are telling people that they’ve caused their own illnesses through some failure on their part in attitude/behavior.
Doctor Neha: It absolutely could be taken that way. My hope and my intention in doing in that was to help them connect the dots, like you mentioned, and to realize that often when other areas of our lives haven’t been addressed, it can show up in the physical realm to get our attention. I don’t believe it’s anybody’s fault that they’ve gotten ill or they’ve gotten sick. I wanted to use it as an opportunity to help them connect to themselves on a different level—and for all of us together to help them have the best chance of not coming back to the hospital. But I can see how it could be seen that way. I want to be clear to the listeners that I’m an internal medicine physician. I’m a mechanical engineer by training. I believe in the physical aspect of science, and I spent more than a decade learning it all. I believe it’s real. And I believe sometimes when people go to the doctors and they say things like, “I can feel my heart racing,” and the doctor comes out and says something like, “Nothing’s wrong with you,” but the patient knows inside something’s wrong. That’s when there’s a disconnection.
When I teach hospital and physician teams, I say, “There’s a disconnect between the patient’s experience and what you’re saying. What you’re trying to say is there’s good news and bad news. The good news is you’re EKG and your enzymes came back and you didn’t have a heart attack. That’s the good news. The physical part of your heart is doing well. The bad news is, you still are not feeling okay. Sometimes, there are other reasons why the heart can start to send us messages inside … We can feel our heart racing or we can feel our stomach turning or we’re getting physiological signs, and sometimes it can be due to other reasons. I always believe that first and foremost you take care of the physical aspects first, and once someone has been cleared from that, you help them connect the dots to how else they might solve what’s happening.”
Kim: Listeners are very enthusiastic about you. One person is saying, “She’s talking about yoga. If yoga is compulsory to study for all medical students, there would be no burnout.” Do yoga and the world would be a better place? Do you do yoga?
Doctor Neha: I do yoga, and I actually do something that even expands on it called Qoya. It’s dance where part of it is yoga and part is movement with meaning. First of all, I want to thank that listener for commenting, because yoga’s amazing. Yoga connects breath work with movement and really helps center and focus us internally. It allows somebody to become present in this moment, and it allows their physiological signals of stress—heart rate, stomach turning, sweating—to start calming down and allowing your sympathetic nervous system to slow down. It is very powerful, and people get so much insight and wisdom through yoga.
What I would tell you is that it helps while they are on the yoga mat and maybe for some time afterward. The next piece is they still have to go back into the boardroom, into the bedroom, into the dining room and have the conversation or deal with whatever initially caused stress.
Kim: You know how most people go, “I need to do less of this or I need to do more of that or I need to drink less Mountain Dew.” Do you think that about yourself or are you in perfect balance now?
Doctor Neha: It’s a constant negotiation with myself. When I beat myself up because I think I’m doing something wrong, or I’m not doing it right, it becomes a battle within me. The way I move into a negotiation is through gratitude and grace for myself. What I say to myself is, “Neha, you’re an entrepreneur. You’re trying to do this differently. You’re trying to pave a new path in medicine. You’re trying to go where many people have not gone before. If you make mistakes, it’s okay. You’re out of balance.” I will always fall off the proverbial horse, but my hope is that I get back on quicker and quicker each time.
Kim: Just failing better.
Doctor Neha: Yes, it’s failing my way to success. If I don’t fail, then I won’t have those lessons to help me do it better the next time. Yeah, I have had to learn to have grace for myself—and a lot of it.
Kim: Good to talk to you. Thank you. Doctor Neha Sangwan, who is one of the speakers at the WorldWomen17 Conference in Auckland [New Zealand].
Awareness Prescription
BURNOUT
If you’re facing a crisis, use the questions that I ask my patients to help you diagnose what’s at the root of your exhaustion. These don’t just apply to disease, but they also help reveal how the different parts of your life are connected and what’s depleting your energy.
- WHY IS MY BODY EXPERIENCING EXHAUSTION/BURNOUT?
- WHY IS MY BODY AT ITS BREAKING POINT NOW?
- SINCE HINDSIGHT IS 20/20, WHAT SIGNALS MIGHT I HAVE MISSED ALONG THE WAY?
- WHAT ELSE IN MY LIFE NEEDS TO BE HEALED?
- IF I SPOKE FROM THE HEART, WHAT WOULD I SAY ABOUT INVESTING IN MY OWN SELF-CARE?
To trusting your intuition,
