June 14, 2019

I am lying on my yoga mat in heart bench, a block under my upper back lifting my chest skyward, and another lower one supporting my head. My feet are together, my knees wide. Class is about to start, and I am wondering why I am here. Like many other people in this class and like the hundreds of thousands of people in yoga and meditation classes all over the U.S., I am here because life is hard and complicated, and I want to believe that something can make it easier, can help it make sense, can help me calm the chaos that pummels my mind and body every day. I am looking for the sweet spot called "serenity," that feeling that life isn't a fast, frightening kaleidoscopic ride every minute of every day.

I like the yoga studio, with its light hardwood floors and soothing sage-green walls, the fading daylight wafting into the skylights, the gentle containment of my purple mat, my small personal space in this larger communal one. And as class begins and the teacher starts to talk, I enjoy her soft, rhythmic voice. I've been coming here once or twice a week for years, always hoping that this will be the day that my adrenaline level drops and my mind quiets for more than just the hour that I'm here, but up until now, that has all been elusive.

Today, the teacher is reminding us about the yogic principles of truthfulness (Satya), righteousness (Astaya) and non-violence (Ahimsa). She dwells on Ahimsa for a bit, going on to say that it doesn't just mean non-violence toward others, but also non-violence toward oneself, one of the building blocks of self-compassion. In fact, she says, while one may move to one's edge in a yoga posture, it is important not to push beyond that, over the "ledge," because of the risk of self-harm. In Eastern tradition, harm to another is harm to oneself, and harm to oneself is harm to all.

We begin our postures, our Asanas, starting with sun salutations. I am with the group, in the studio, but my mind is stuck in an exploration of Ahimsa. The phrase "do no harm" is swirling through my mind, and a connection is made for me.

Thirty years ago, "do no harm" was not part of yoga for me, but part of medicine. "Primum no nocere" — first, do no harm. The basic tenet of medicine. As many will recall, this phrase is not actually part of the Hippocratic Oath, which doctors traditionally took, promising to use "treatment to help the sick according to one's ability and judgment but never with a view to injury and wrong-doing." Of course, in the Hippocratic Oath, which was so much a statement of its time, we also vowed not to perform abortions... so to me, the idea of "Primum no nocere" is more relevant, and more profound. If I add the Physician's Oath of Maimonides, which says "In the sufferer let me see only the human being," I always felt like I had the important stuff covered. But today, in this class, I realize I have made a mistake. I have always applied my obligation to "do no harm" to others, but I have forgotten to apply it to myself.

You might think that, at 58, I should have figured this out a long time ago. And it's not that I didn't think about self-care and about my own needs — or I wouldn't be here, right? But meeting one's own basic needs is not the same as being non-violent toward self, of doing no harm to self. Medicine, though, is a punishing profession, and many of us who go into it are, by nature, self-punishing. The hours worked in training and the lack of sleep on call, as I remember, were painful and not in line with health and well-being. Until I left primary care almost a year ago, I was still getting up, sometimes many times a night when on call, and would sometimes go to work the next day after only a few hours of sleep. I worked through lunch. I still do that — now that I am doing shift work, I often miss meals when things are busy, and I am on my feet for 12 hours when my back and feet are aching. That is a form of violence toward oneself.

I also, like most of my colleagues, went to work as a primary care doctor when I was sick. Often sicker than the patients! The tacit understanding was that "doctors don't take days off." The problem is that clinicians have full patient schedules, and canceling patients is a huge inconvenience to those patients, especially the ones who took time off from work themselves to be seen. It's also a big financial problem for institutions who employ doctors. There is a huge incentive for those institutions to have doctors come in even when they're sick. In most settings, a sick day for one doctor means that all their colleagues have to work harder to pick up the slack, so doctors encourage each other to work when sick or injured. And these are just some of the physical ways in which we are violent toward ourselves and each other.

The emotional and intellectual violence may be even worse. The expectations that I had of myself as a doctor for most of my career were outrageous, and sometimes the expectations that others had of me were as well. I expected myself to know everything. Fortunately, when I didn't, there were resources — online, in books, in the form of friends and colleagues. But when I didn't know something I thought I should, I beat myself up over it. I questioned my competence and assumed other people would think I was a bad doctor if I needed help. I expected myself to be a pillar of strength for my patients, and to be kind, warm, reassuring and honest, all at once, all the time. I believed I should be on top of my game whether it was 8 a.m., 5 p.m., or 3 a.m.. I berated myself if I was running more than a few minutes late, and apologized profusely.

For years, I drove myself in this way. Along with one partner, I ran a practice. I know she had the same high standards for herself as I did, which is how we worked together. And when I went back to academics seven years ago, I had these standards for my teaching and writing as well as for my medical practice. To top things off, in the era of EMRs, "report cards," prior authorizations, and short-staffing in medical offices, I was also supposed to keep my head down, do my work, and be a pliant, uncomplaining cog in a dysfunctional system. I was never supposed to get upset or frustrated or angry. When others, either patients or officemates, got angry at me, I was supposed to understand and apologize, regardless of the circumstances.

Of course, these expectations are doomed. Nobody is perfect. Nobody can be expected to work day and night, through illness and injury, have an infinite fund of knowledge and be a paragon of personal virtue. We all get sick sometimes. We need sleep and food to keep going. We have families who need and want things from us. We have our own wants and needs. We get flustered and frustrated when systems, computers, and people who are supposed to help us fail to do so. When support systems are not what they should be, and we still need to do our jobs, we run late. Sometimes very late. To deny any of this is Himsa, violence, to ourselves. If we are going to practice Ahimsa, we must let go of the perfectionistic, unrealistic and very harsh expectations of ourselves and our colleagues, the ones that turn medicine into a sure recipe for burnout.

I'm better at self-compassion now. Last week, I had a flu-like illness. I called scheduling at work the night before I had a shift scheduled. They got someone to cover it — no questions asked. As I am new to urgent care; I have to look things up all the time now. I shrug and click on the "UpToDate" icon, and find out what I need to know. Sometimes I call someone more experienced for help. It doesn't mean I'm stupid. (When someone asks me for help, I don't think they're stupid, either.)

I might get hungry and not have time to eat a meal, but I keep a protein bar tucked in my pocket and a full water bottle on my desk. Sometimes patients are kept waiting longer than they should be — if I am suturing or dealing with chest pain, there's not much I can do about that. So I apologize, and then I move on. And yes, I sometimes curse when the computer frustrates me. I try not to let patients hear me.

I still believe that when I’m working, the patient comes first.  But that doesn’t mean I come last. I take care of myself, too. I also try to care for my colleagues, and remind them to care for themselves. I speak up, with confidence, when I need something, and encourage them to do the same. I'm practicing Ahimsa, toward others, but also towards myself.

Rosalind Kaplan, MD, FACP
drrozkaplan.com