Episode 173: Real Self-Care with Pooja Lakshmin, MD
Kaden Page, David Puder, MD
David Puder, MD, Kaden Page, and Pooja Lakshmin, MD, have no conflicts of interest to report.
On this week’s episode of the podcast, we interview psychiatrist, author, and founder of Gemma Women, Dr. Pooja Lakshmin. Dr. Lakshmin founded Gemma Women for the purpose of educating women on cultural and social structures that impact their mental health. Gemma also provides community groups, evidence-based conversations, and courses covering topics such as stress, inequity, and structural violence. In her new book, Real Self-Care, she discusses personal experiences that led her to create this transformative movement to redefine wellness.
Dr. Lakshmin’s Journey
By her second year as a psychiatry resident, Dr. Lakshmin found herself deeply unhappy and jaded by the traditional medical schooling system. She became so burned out that she dropped out of her residency program and even ended her marriage due to the strain. After having pursued the most prestigious education available to fulfill her desire to help others, she instead felt betrayed by the lack of ability she found in this system to impact change for patients at a fundamental level. She wanted to see social injustices addressed at a more hands-on scale and give more than just temporary solutions to the issues she witnessed each day.
Continuing her search for a more effective system, she went to the opposite extreme from mainstream medicine and joined a spiritual commune, effectively a cult, that studied female sexuality in conjunction with the neuroscience lab at Rutgers University in San Francisco. What she learned during her time in the commune greatly shaped her future passion for women’s mental health.
Ultimately, however, the system at the commune proved much more unhealthy than it originally appeared to be and she found herself in a similar end as with medical school. It led Dr. Lakshmin to determine that the only way to enact real change is to look inward. As she began a new journey within herself, the pull to challenge the limitations traditional systems put on individuals evolved into a message for all that what we need isn’t self-care, but boundaries across a wide spectrum, which she champions in her book, Real Self-Care.
Faux Self-Care
Faux self-care is a term coined by Dr. Lakshmin that she defines as temporary solutions to systemic problems, such as meditation apps and spa days. While not inherently wrong or bad, she suggests that these types of superficial self-care do not offer relief from the root causes of burnout and exhaustion which may, at their core, stem from culturally-embedded issues such as racism, sexism, and unhealthy capitalistic societal practices.
Dr. Lakshmin points out that, for example, there is no possible amount of mainstream self-care that can relieve the burnout created by a 40-hour work week with no childcare. Instead of seeking the change within ourselves, faux self-care keeps our focus on outward change, over which we have very little to no control.
Provider Burnout and Increased Connection
When it comes to burnout in medical students, the potential is extremely high due to the intensity of the learning environment. Dr. Lakschmin recalls one of her most difficult wake-up calls to the seriousness of burnout being when a fellow resident committed suicide. It caused her to take a hard look into the stress of the schooling system and how it contributed to this tragedy, ultimately adding to her own decision to temporarily drop out.
While there are many uncontrollable aspects of medical school and residency training, research suggests students that have a healthy connection with their supervisor report less burnout and more fulfillment during their student career.
A study by Haglund et al. (2009) conducted an analysis of 125 third-year medical students and measured the association between stressful events encountered during clinical rotation and student well-being. Using the Beck Depression Inventory and Posttraumatic Stress Disorder Checklist (civilian version) to monitor scores, it was found that rates of both depression and posttraumatic stress were significantly increased (P < 0.05) throughout the academic year before returning to near baseline at the end. Witnessing patients experience trauma did not worsen psychological outcomes; however, poor role modeling by physician superiors increased medical student depression scores.
Puder et al., (2022) created a tool, the connection index to assess interpersonal relationships in the medical education system. Using the 12-item, 7-point Connection Index, the study examined how the relationship between resident and supervising attending affects the clinical learning environment, as well as resident well-being. Results showed a significant association between greater connection and less burnout (P = 0.001 while measuring emotional exhaustion), less mistreatment or bias, and higher attendance to supervision sessions.
Additionally, Panagioti et al. (2017) performed a meta-analysis of 20 separate studies that included 1,550 physicians and assessed the effect of controlled interventions on provider burnout. Interventions were either physician-directed (mindfulness, CBT, personal coping skills) or organization-directed (changes in schedule, reduction in workload). Results showed that physician-directed interventions were associated with a small significant reduction in burnout, while organization-directed interventions were associated with medium significant reduction in burnout. Overall, it was concluded that organization-directed interventions were significantly more effective than physician-organized interventions in reducing the level of burnout (P = 0.04).
The data produced by these analyses support Dr. Lakshmin’s movement that changes presented by the institution, rather than students or the providers, provided more systemic change in the level of burnout among students. Faux self-care interventions, such as extra classes and other interventions that only add to our schedules and mental load, do not address the underlying issues; adjusting the overall system offers more lasting benefit to students.
What Is Real Self-Care?
Real self-care may look like being able to admit there are aspects of your job where you are being treated unfairly and identifying how to address the situation. It may be recognizing that some aspects of the job are difficult due to its nature and searching for ways to lessen the impact of these stressors. These are boundaries that can create buffers from overwhelm.
Simply put, real self-care is about reclaiming your power and points of agency in life. It produces inward changes instead of temporary relief, which has a ripple effect on the rest of the ecosystems around you. When enough people pursue these inward self-care changes, we can collectively reach a tipping point that influences change at the systemic level.
Dr. Lakshmin hopes to reconcile the thought that real self-care is one climactic moment when dramatic change occurs; it is actually the accumulation of hundreds of small decisions that consequently steer the quality of your life in a more sustainable direction.
Real self-care involves a level of critical thinking that challenges the current social and cultural norms. At first, it may be isolating to push against these standards. Dr. Lakschmin suggests finding your “tribe” that is willing to think outside the box with you and encourage curiosity in the way the world operates.
Practicing Real Self-Care
The first steps in practicing real self-care are identifying your values, acknowledging the issues that do not align with those values, and recognizing what agency you have over improving the circumstances. Dr. Lakschmin says of real-self care, “It is a verb, not a noun…it is not about the Thing. It is about the process you take.”
Real self-care is a state of awareness that results in this self-care being weaved into the daily context of your life, instead of fifteen minute or hour intervals, through many small decisions.
When beginning the inward self-care journey, Dr. Lakshmin offers four guiding principles: boundary setting, compassionate self-talk, identifying personal values, and asserting your power.
Each of these principles is part of her Real Self-care Compass: the what, how, and why questions that facilitate paving the path forward for your personal self-care journey.
What? This involves setting goals for each area of your life: career, personal, etc.
How? Ask yourself how you would like the process of achieving your goals to unfold. This should be based on your own personal desires instead of being influenced by the approval of others or how others might accomplish the same goals.
Why? Dr. Lakshmin describes the “why” as a personal manifesto. The answer to this question should be the core of what drives you and brings fulfillment.
Conclusion
Each area of our lives could benefit from being put through a filter of real self-care. Making small, consistent adjustments to what we have control over can accumulate into lasting personal change and happiness rooted in purpose and living according to our values.
If you are a medical student or resident, training by nature is more life-zapping than life-giving. We as a podcast hope to encourage you during this season to stay true to your values and support your efforts to continue being creative and curious.
Pooja's book, REAL SELF-CARE: A Transformative Program for Redefining Wellness (Crystals, Cleanses, and Bubble Baths Not Included), is available in audiobook (self-narrated), e-book, and hardcover at www.poojalakshmin.com/realselfcare.
Pooja's IG: @poojalakshmin
Pooja's women's mental health education platform, Gemma Women, was co-founded with Dr. Kali Cyrus, M.D., MPH. Dr. Lucy Hutner, M.D., serves as a strategic advisor and consultant to Gemma.
References
Haglund, M. E., aan het Rot, M., Cooper, N. S., Nestadt, P. S., Muller, D., Southwick, S. M., & Charney, D. S. (2009). Resilience in the third year of medical school: a prospective study of the associations between stressful events occurring during clinical rotations and student well-being. Academic medicine, 84(2), 258-268.
Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., ... & Esmail, A. (2017). Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA internal medicine, 177(2), 195-205.
Puder D, Dominguez C, Borecky A, Ing A, Ing K, Martinez AE, Pereau M, Kashner TM. (2022). Assessing Interpersonal Relationships in Medical Education: the Connection Index. Acad Psychiatry, 46(6), 683-691. Epub 2022 Jan 22. PMID: 35064549.