AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2003, Volume 5, Number 9.

Clinical Pearl

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A Physician's Guide to Balance

A physician describes how practicing and teaching yoga helps him to maintain work-life balance and emotional well-being.

Steven Landau, MD

I couldn't practice medicine without doing meditation and yoga.

I began doing yoga at the age of 10. I thought to myself, "This will save the world!" after finishing a brief rest in the corpse pose. Then the second thought came, "If only people will do it." (Aye, there's the rub.) Then I stopped doing it.

photo of Steve LandauI started doing meditation regularly in Harvard in my senior year of undergraduate training. It helped calm my mind, and I've been doing it ever since, with the Ananda Marga Yoga Society. Now I teach classes in prisons, battered women's shelters, and my own Johnston Memorial Hospital. I even have a straight scientific talk I do for CME on Medical Aspects of Yoga and Meditation. And you're probably wondering what all those initials mean after my MD. The FAAFP is a symbol of family practice, the primary holistic discipline in mainstream medicine. The ABHM is the sign of the even more holistic discipline in non-mainstream medicine, the American Board of Holistic Medicine. The RYT stands for Registered Yoga Teacher.

I was asked to do this article because of my association with the Yoga Alliance, a non-profit group of idealistic and practical yoga teachers who also want to save the world through yoga. They've set up minimum standards of training in this art and science that was previously almost totally unregulated, and is still usually taught from master to disciple.

Have you noticed how much I've used the word "I" so far? That's a little like the practice of meditation. First you get the "I" trash out, and after a while it all gets handled nicely. Then, as your selfish concerns wear off, you start getting the larger picture and transcend into the realm of bliss.

Ashtanga (8-limbed) yoga incorporates the multiple elements used to put out the trash and keep it out. It has parallels to medicine, as follows:
1. YAMA (intro-external controls)
a. Ahimsa—noninjury by thought, word, or deed ("First, do no harm").
b. Asteya—abandoning the thought of stealing or of depriving someone of their due (keeps me clear of Medicare fraud).
c. Satya—benevolent truthfulness—action of mind in the right use of words with the spirit of welfare (the "art" of medicine: what do I tell, to whom, and when? Tell someone "You look great!" even though they're feeling terrible, so they'll actually start looking and feeling better).
d. Brahmacharya—looking upon everything as a manifestation of Consciousness, and not just as the crude form (the holistic approach—we're not just bodies and chemicals).
e. Aparigraha—non-indulgence in those material amenities that are superfluous to the maintenance of life (with due regard to the prevailing standard of living in the society at large).

2. NIYAMA (extro-internal observances)
a. Shaocha—purity and cleanliness, mental and physical (wash your hands often. Wash your mind often too).
b. Santosha—contentedness with the fruits of reasonable labor (no more 80-hour work weeks, if we can help it).
c. Tapah—willingly undergoing pain for the benefit of others. Service without thought of reward, just because you recognize the Supreme in the object of your service (we all do indigent care, at home or abroad).
d. Svadhyaya—scriptural study with a view to understanding the underlying meaning (read your journals).
e. Iishvarah Pranidhana—chasing the Supreme—establishing oneself in the Cosmic Shelter; looking upon oneself as the instrument rather than as the doer ("I will lead my life and practice my art in purity and holiness" --Hippocratic Oath).

Yoga requires balance in the mind, body, and spirit. But where do emotions come in? Emotions are just thoughts with enough power to stimulate hormonal and physiologic reactions. Yoga deals with these directly. Here's how:

ASANAS—yoga postures

1. Asanas balance out the hormones. Don't ask me how—you just have to experience it. There's been no convincing scientific data that I've seen to show that cortisol or thyroid levels go anywhere predictably. That's probably partly because people doing different studies use different techniques and yoga postures, of which there are thousands. One way that asanas work is by pressing on chakras. These are psycho-physical plexi corresponding to various points in the body. Known for thousands of years, they also correspond to conjunctions of voluntary and involuntary sphincters, sympathetic and parasympathetic nervous plexi, and major endocrine glands. The yogic description of the chakras and nervous system also looks just like a common rendition of the caduceus (see diagrams 1, 2).

2. Muscles get stretched out and utilized in a way that tones them and doesn't fatigue them terribly much. An overall sense of euphoria develops. Stretched muscles work better and with less effort. The day flows smoother.

3. Self-massage following asana practice causes release of immune modulators from the skin. Feels great, too.

4. Corpse pose, everybody's favorite, allows total release from stress, and is the basis for the Jacobson desensitization technique. You can do it at lunch for a few minutes after you've been on call the night before. Works well.

PRANAYAMA—Breath and energy control
With the help of asanas, and certain specific breathing exercises (slow breaths at 1-2 times/minute, or alternate-nostril breathing) one gains control over the physiology of breathing. This enhances lymphatic flow (the lungs and diaphragm are the main pump to get lymph flowing from the rest of the body into the thoracic duct) and thereby the immune system. It also calms the nerves and emotions. By breathing more slowly, habitually and consciously, one's stress reactions are diminished. Have you ever noticed that tachypnea causes anxiety? Hence the morphine used in terminal care. Yogis use endorphins instead. When you're tired or tensed in the office, a few deep breaths will help put you at ease.

PRATYAHARA—Withdrawal of the attention from the sense-objects
Meditation is the practice that convincingly alters the mind in a very quick and reproducible fashion. Brain waves synchronize, various parts of the cerebral cortex are activated while others are deactivated, and a sense of bliss ensues fairly reliably. This, of course, depends on disconnecting the flow of constant stimulus from the outside world. When you get pretty good at this, intuition develops. Do this twice a day, preferably before eating, but anytime is okay.

DHARANA—Concentration
With practice, the mind becomes steady. Use of a mantra (Baba Nam Kevalam is one—means "Only the Name of the Beloved"), or focusing on the breath, or counting "OM - one, OM – two," or staring at a candle or a blank wall, or reciting Ave Maria, all of these work for some people. Try your own. You'll find it amazing that you have so much thought in your head that you can't clear out initially. But after a while, you do. You'll feel great, and it even lasts throughout the day. Make sure you sit up straight (in a chair if you do TM or Kabala style, or on the floor like a yogi. Pillows and back supports are allowed).

DHYANA—Meditation
Once your concentration becomes good, you really start to enter the realm of bliss, where your mind flows like oil or honey from a pot.

SAMADHI—Merger
At this point, you've abandoned your concept of self and merged it into the Self—the object of your concentration and meditation. Then you realize that the Self has really been meditating on you the whole time. This unity is really transcendent, and transmits unconsciously to all your patients and all those around you.

Having said and done all that, there's still a need to achieve and maintain balance in the society. So, here's a tip from Tony Robbins: make a wheel, with spokes, each arc of which represents a segment of your life. Then fill them up to the level at which each segment is functioning at this very moment in time. Are they equal? Then your wheel of life is going smoothly, and can go around very fast. Are they unequal? Then your wheel of life is going to go bump-bump-bump down the road and be very uncomfortable. So now you know which portions of your life you need to concentrate on and improve (see diagram 3).

Another critical point: How do you know when to use intuition and when to use intellect? When do you listen to that "still, small voice"? The answer is that you listen to it all the time, and obey it when you can. You learn to combine its wisdom with the practicality of the intellect and science that you've been taught, and you'll find that it works wonderfully well.

Last point: Always see the bright side of everything, and focus on it. By worrying constantly about bad outcomes, you'll bring them about. By focusing on the good outcomes and how you'll make them happen, you'll discover ways of bringing that about, too. You always have the choice. And as my guru, Shrii Shrii Anandamurti, told me, "Forget all past mistakes. Live your life afresh from this very moment. Do something concrete for the suffering humanity. And smile a little bit!" And with that, he took his hands and made my lips smile a little bit. And so you do, too.

With love and best wishes,
Steve Landau

drawing of new a balance wheel

Diagram 3
(drawing by Steven Landau, MD, idea taken from Anthony Robbins' tapes, The Time of Your Life, 1-800-898-8669)

Steven Landau, MD, is an attending physician with Johnston Memorial Hospital in Smithfield, NC, and employed at a rural family health clinic, Johnston Family Care Center, in Kenly, NC. He also holds positions as adjunct instructor at both the University of North Carolina-Chapel Hill's School of Medicine and School of Nursing.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.