E123 Janice Pasieka on Shinrin-yoku, yoga, and other strategies to fight stress from COVID19
Listen to this podcast on SoundCloud
Eric Pauli 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:42
This week, we were lucky enough to be rejoined by Dr. Janice Pasieka. Dr. Pasieka is an endocrine surgeon at the University of Calgary, and we asked her to come back on the show after she gave a recent Grand Rounds for the province of Alberta, talking about stress and burnout, especially in the context of COVID-19. We particularly think listeners will enjoy her discussion about nomophobia.
Chad Ball 01:06
For anybody that maybe didn't hear your initial episode with us, we're wondering if you could just refresh where you're from and what your training pathway looked like.
Janice Pasieka 01:17
So I'm here at the University of Calgary; I'm an endocrine surgeon within the Division of General Surgery. I did my medical school at Western Ontario, interned out in Vancouver - I'm old enough to say I interned - and then I came and did my general surgery residency in Calgary, and then worked in the lab for a year with one of the endocrinologist and then did a clinical fellowship with Norm Thompson down at the University of Michigan in endocrine surgery, followed by half a year with Bertil Hamburger at the Karolinska Institute in endocrine surgery before being recruited back here, and I've made my career here in Calgary, solely practising endocrine surgery.
Ameer Farooq 02:12
Dr. Pasieka, thank you again for joining us on the show. You gave recently a really phenomenal talk and unique talk about stress, Shinrin Yoku yoga and other strategies to fight against COVID-19-induced stress. I'm curious what the motivation was right off the hop to give this talk.
Janice Pasieka 02:32
Yeah, I think it came from my observation of what was going on around me, my own personal reflection of what was happening to me personally, and then seeing what was happening around with my colleagues and you know, the pandemic has put unprecedented stressors on us, right from the get-go and continued and who would have thought continued on greater than two years. And what I was feeling personally was that I was under a lot more stress than I would normally have felt; we work in very stressful job as surgeons. But this was unprecedented, and I felt quite different. And I also observed that many of my colleagues and people within the department of surgery in the operating room, everything was a little different. I then started to try to figure out what it was that I was doing and when I was feeling back towards more myself. And it started with knowing that during the height of the pandemic, I would head out into the mountains and out to a cabin that I have out there and that's when I could decompress, and I could start to feel normal. And I didn't have all of this stress sort of encompassing me. And with that, I started thinking, "Well, maybe it's being out in the fresh mountain air, maybe that's what's making things less stressful for me." And that got me looking at a whole host of things that help reduce our stress and into a body of literature that I didn't even know existed. And the impetus for putting it together and presenting it is I really just wanted to remind everybody that for us to take care of our patients and to take care of our families, we need to stay healthy. And we needed to address this. And I was hoping that by giving that presentation, it would stimulate some of the people in the audience to rethink what they do and how their lives have changed and what they could do to make it less stressful.
Chad Ball 05:12
For some of the listeners that obviously didn't see the talk. Dr. Pasieka, can you define for us what subclinical Cushing's disease is and how it relates to what you're referring to and, in particular, I was wondering if you could go a little bit deep. You talk at length about hair, cortisol levels and changes measured after COVID, and that whole domain was fascinating.
Janice Pasieka 05:35
So, subclinical Cushing's, I mean, I think we all know what Cushing's syndrome is and the phenotypic manifestations of excess cortisol, with the buffalo hump and the central obesity, etc. But in mild autonomous cortisol secretion, or what's called subclinical Cushing's, this is a disruption of the hypothalamic pituitary axis, so that there is a higher level of cortisol that's been autonomously secreted, but the patient or the person themself does not have the clinical manifestations of Cushing's. It's a biochemical diagnosis and we started to see it and as surgeons, we make that diagnosis in the biochemical workup of adrenal incidentalomas, so they all get screened for function, and 20% of adrenal incidentalomas will have autonomous cortisol secretion, and yet the patient does not look Cushingoid. So that has morbidity. With that mild autonomous cortisol secretion, you've got hypertension, there is increased obesity, dyslipidemia, cardiovascular disease is higher. And so it has morbidity, and therefore should be treated. And as surgeons, if they had an adrenal lesion, we would take it out. So I then flipped it on to: If chronic stress is another means of breaking through our normal, acute stress response. In other words, we get cortisol resistance, and now we have a baseline elevated cortisol, and we have autonomous cortisol secretion above and beyond what we should. What happened there was the pandemic - enough of a chronic stressor for all of us - to produce this in us by causing cortisol resistance. And so I looked at data that showed that pandemics and epidemics are a stressor in health care workers. And there's been a lot of literature about that increased anxiety, depression, substance use during pandemics and epidemics throughout the world. And then look specifically at the COVID pandemic, and try to see if there was any evidence that there was a higher level of cortisol, which is really called the stress hormone in health care workers living through and dealing with the pandemic. And one of the studies that I found was looking at hair cortisols. And the beauty of hair cortisols is that you can measure retrospectively so when your cortisol levels are elevated, it's in your hair, and then it stays in the hair. And so looking at segments of hair that would have grown during the pandemic, and comparing them to segments of hair, before the pandemic started, you can look and see if there's a difference in cortisol. And this one study from Slovenia did show (it was on nurses) had a higher level of cortisol levels in the segments of hair that was growing during the pandemic versus the retrospective segment of hair that was done before the pandemic even started. And that really was the body of literature that told me yes, this is a chronic stress problem. And we probably all had a degree - and probably still do have a degree - of autonomous cortisol secretion, but it's not manifesting - we're not looking cushingoid. It's manifesting by the higher cortisol levels and the cortisol resistance is then allowing more cytokines to be released in the body. And those cytokines, interleukin 2, TNF alpha are affecting the hypothalamus that's causing anxiety, that's causing depression. They are increasing our hypertension because of the mineral corticoid effect. And, yeah, I think having a physiological effect on us.
Ameer Farooq 10:31
I think you presented such compelling data to support, I think, what many health care workers around the world have really been feeling. And I thought that was a pretty powerful demonstration of that lived experience. You then went on in your talk to talk about a number of strategies, for actually combatting stress. And again, this is fascinating to me, because you presented some really compelling data, again, to support a number of these different strategies. Could you talk a little bit about some of these strategies, some of which I had never heard about? I hope I'm saying it right: Shinrin Yoku. Can you talk a little bit about Yoga, Shinrin Yoku and green space?
Janice Pasieka 11:21
Yeah, sure. But remember, you know, Ameer, you can find in the literature things to support your hypothesis. I found it. And that's the data that I gave you. And I didn't give you data that disputed it. But yes, it is compelling when you go down that route. So what I looked specifically for were non-medical ways of decreasing cortisol. And there actually is a whole host of literature on stress reduction, using non-medical means, and the ones that I presented - yoga was one of them and yoga, it has been shown to decrease our interleukin 6, increase our brain derived growth factor, which increases our neuroplasticity, and decrease our cortisol levels after going through programs of yoga. And many of the studies are taking patients or subjects that are under a great deal of stress, putting them through a 12-week program of yoga, and then measuring before and after. Shinrin Yoku is a Japanese tradition. And it translates into what's called "forest bathing," and literally is going out into the forest and being surrounded by nature, completely away from any urban sounds and environment. And this is a long-standing tradition of the Japanese and has been studied extensively showing it decreases blood pressure, diastolic pressures, decreases heart rate. And when looking specifically at salivary cortisol levels, it will decrease one's cortisol levels, compared to walking in an urban environment. And the other one was dream space. Not everybody can get out into an urban environment. And there's a lot of places in the world that don't have access to that. So what about just being able to walk in the park or dig in your garden or take the dog for a walk in a park? That is called "green space exposure"; Can that decrease the cortisol levels? And there's a lot of data on that and that literature really is one that urban planners are using. It's compelling enough, although it has a degree of heterogeneity that it's not as clear and crisp as some of the other studies, but the overall concept that green space is important to us in decreasing our stress levels. Urban planners are using that data, so when they build a community, there is green space that is rolled into it. I think during the pandemic - when we had to be isolated and we weren't allowed to go anywhere - a lot of people that lived in apartments and didn't have a backyard to sit in, really craved for the ability to be in a green space and walk around because it has a calming effect on us.
Chad Ball 15:10
That's so interesting. All those strategies, in particular, are probably unique to individuals in terms of what they pursue and how they achieve that end goal and that target that you're talking about. You talked a fair bit about the impact of yoga in particular in your life and how you use that, and of course, your cabin, as you mentioned. I was wondering if you could just reflect on the yoga side of things, in particular as a surgeon, how that intersects?
Janice Pasieka 15:41
I took up yoga when I started running and training for half marathons and recognized I needed to keep flexible. I had sort of poo-pooed yoga for what I knew about it up to that point, but I walked into a yoga studio, that was "yoga for athletes" was the type of yoga it was, and then I got completely hooked on it, in the sense that I soon recognized not only did it help with increasing flexibility in my running, but it was invaluable to me after a long day in the operating room. We work in a non-ergonomic environment, and then getting into yoga to help take away the stress in the back of your neck and in your arms and from standing in one place operating all day was just invaluable. I craved for it after a long day in the operating room, and still do to this day. And recognize if I go a week without taking a class how different I feel. I know residents all hear this [podcast], so if I could have taken this up as a resident, I think that would be my one advice: as surgeons, you need to do something like this. Also, yoga is really interesting. For those of you who have practised it, you recognize that it also incorporates the strategy of mindfulness, which is a way of just putting your mind into the present. And that in itself has been shown to decrease stress. So learning that technique, I think is also invaluable as surgeons to really have a way of tuning out all of the clutter and things that are going on in our lives after a long day in the operating room and being just present for yourself. It's invaluable certainly to me.
Chad Ball 18:18
One of the other things that you talked about and that fits so nicely in this pathway was nomophobia. Can you define for our audience what nomophobia is? I thought that was just awesome.
Janice Pasieka 18:31
One of the other things in my hypothesis that was when I was out at the cabin, that's when my stress levels went down, and I felt more normal, was that the cabin has no access to the Internet. I have no cell reception out there, no TV, no radio, so I'm completely disconnected. And so I thought okay, maybe it's the disconnection when I'm disconnected from my phone and the electronic world that we live in. It was decreasing my cortisol levels. And so I tried hard to find data to support that. But I couldn't find it specifically for cortisols - but interesting - I then ended up learning about nomophobia. Nomophobia is the fear of being without a working smartphone. And it's a true phobia. It was described in 2015. And it's on the rise. So, two or three years ago, before the pandemic, moderate-to-severe nomophobia was found in just over 50% of the population and less than 3% of the population don't mind being completely disconnected or enjoy being disconnected off their phone. But now it's on the rise. So it's over 65% of the population have moderate-to-severe nomophobia. And it's also been shown that you can measure the degree of nomophobia in an individual with validated tools, that if you suffer from severe nomophobia, you're 14 times higher of having problematic Internet use - and that means gambling, distracted driving, getting on the wrong websites and going down a pathway. It's an interesting phenomena because we need that connection. We need to be connected; our world now depends on it, and certainly during the pandemic, without it, we would have been more socially isolated, because this allowed us to, while we were in lockdown, be able to still communicate with family and friends and stay connected, work from home, continue to function in a way. And yet if we suffer from severe nomophobia, it's now become a pathological obsession with your phone. And it's interesting that professionals are more at risk of moderate-to-severe nomophobia. There was one study that showed that our medical students - 80% - suffer from moderate-to-severe nomophobia. And I think, you can look around, you can walk downtown, or you can just walk outside and you can see people not enjoying being outside but looking at their phone, and recognizing we're becoming too dependent on this connection, in my opinion.
Ameer Farooq 22:02
This is not a problem unique to medicine or unique to surgery. I mean, if you really want to think about it in a philosophical way, Blaise Pascal said that all of humanity's problems stem from a person's inability to sit quietly in a room alone. So really, in some ways, we're dealing with something that is a worldwide global phenomenon that affects all of us. And you listen to the talks given by Facebook ethicists or Google's ethicist. And they talk about the fact and the way that phones are designed to actually keep you hooked to them. Even when it comes to the colour of the notifications - one of the things, for example, that they talk about is if you make your phone gray scale, without colours, that actually helps you to not feel the need go on your phone all the time. But the point that I'm trying to make is that I think these things are designed in that way to keep you hyper-engaged and connected. And so I wonder what your thoughts are about surgeons trying to deal with what is a worldwide global endemic problem? And do we really even have a chance in trying to fight against this nomophobia? I guess, in some ways, as you mentioned, we're one of the few professions that actually have the ability to go into the OR and just actually turn everything off. But I'm wondering, and I'm curious what your thoughts are - as surgeons, how we battle against the hyper- connectedness and inability to just be present in the moment? And do we even have a chance?
Janice Pasieka 23:50
Yeah, good point. And I think what we have to do is, we have to be aware of it to be able to change. We have to acknowledge it and then start to look at strategies if we're going to change it. You're absolutely right. Surgeons, when we're in the operating room, we can be disconnected, but we make up for it. When we come out of the operating room, we're multitasking. You're on the computer, you're on your phone, you're phoning patients, families, dealing with emails, and putting in orders, etc. So, it appears that it's here to stay. You know, it's part of our world. But what we have to do is we have to balance how we use the Internet, at work, with our leisure time and we have to be very cognizant of not always being connected. There are studies to show a better quality of life if you could contain your work time Internet use to less than 28 hours a week. But also at the other extreme, if you had no access to Internet at work, you also had a poor quality of life. So having some connection is important. And then how we use it in our leisure time. And I guess that comes down to you do have to disconnect, if you want to practise mindfulness, if you really want to go out and practise Shinrin Yoku and be out in the forest, you shouldn't be walking in the forest, looking at your phone or chatting and FaceTiming people while being in the forest; you should be enjoying the forest. So I think, for me, and what I wanted to get out of that message is just, we have to be cognizant of it, we have to then say, "You know, once in a while, it's okay to disconnect." And we shouldn't be penalized for disconnecting. And it can be stress-inducing to those that really depend on it. But I would challenge every surgeon that's listening to this, try it, try to disconnect for one day or for six hours on a Saturday and just put the phone away and start to enjoy the simpler things in life. I find it to be very helpful. I just worry that if we're not cognizant about how much we use the phone, or the connection, that it will change how we see and interact with the world. A good example is, I could have a dinner party at the house, and we're having a casual conversation and somebody says, "Yeah, but who, wrote or who said this quote?" And inevitably, a couple of people will go into their phone and immediately Google it and answer the question and the conversations over. If we have that same conversation up at the cabin, there is no way to Google it, people may try to reach for their phone. But now we have to have a conversation; we all have to start thinking about it and putting our thoughts together to come up with the answer of that question. And it's just a much more enriching social interaction, for us to have a conversation that doesn't end because somebody looked it up and answered the question right away.
Chad Ball 27:41
It's such a great and honestly thoughtful anecdote. It's interesting to think about, I want to put you on the spot just a little bit here, Dr. Pasieka. Some of the strategies and things you're talking about, obviously, are sort of medium-to-extended intervals. So taking a day, trying to be mindful, taking six hours, as you said, you know, give it a try. But I'm curious, recognizing that each day obviously, in your practice is different, you do general surgery call and in addition to a busy endocrine practice, but what are some of the little daily timeouts or strategies that you use, maybe in between things or at the beginning or the end of your of your typical day? How do you actually mechanize this philosophy on a daily (or at least try to) on a daily basis?
Janice Pasieka 28:35
Yeah, great question, Chad. Everybody has to figure out ways and adapting them for their own life and their other commitments outside of surgery. I'm no expert at it, but am constantly trying. One of the things that I did is I took my Alberta Health Services email off my phone, so my phone does not connect to my work email, and therefore I've restricted my work email - I have to be in the office. Yes, I can get it at home and I can log in and do all of that if I have to. And I do that occasionally on weekends, but I separated it, so work is email, I will answer those when I'm physically at work. And if you need to get in touch with me, Chad, you know how to use my personal email and that will come to my phone. So that's one thing. I was very bad at spending weekends coming in and writing and doing research in my office and giving up a Sunday afternoon, Sunday evening to do that. And so I've stopped doing that. If I'm not on call, I try to avoid the office at all costs and if I do have to work or write a paper or do something, I can connect it and do it at home. But that's less stressful, a little bit different environment. I am not a very good yoga practicer outside of taking a class. I sign up for a class - every week, I try to make sure that I've booked a yoga class and I've gotten a couple of days in the gym, so those kinds of strategies become part of what I do. So I don't know if that completely answers your question. And then weekends away or when travelling, disconnecting and enjoying the moment. But you can't do it every day; things throw a wrench in it, but if you try to be a little bit more disciplined about it, at least maybe 75% of the time, you're going to be successful.
Chad Ball 31:15
I think that's a great point. It'll probably look different for all of us, given our different lives and demands, but probably the important thing is to be really thoughtful about it, and sit down and put the mental equity into how to make those changes, and then, probably trying them and if it doesn't work, then try another.
Janice Pasieka 31:37
Absolutely. And don't try to change everything all at once or you'll get stressed. You have to take one thing that you're willing to say, "I think I can sort of try this or I can disconnect on Saturday evenings, most Saturday evenings, or whatever it is," and then just try it. And yeah, it's gonna be stressful the first couple of times, but then you're gonna start to enjoy the benefits of it and seeing how it allows you to do other things. And that's what it's all about; we have to stay connected, we have to stay engaged, and we have to stay healthy to care for our patients and to be able to go into the operating room and be at the top of our game. Every single day. Our patients expect that of us. But not easy to do if you don't have your personal life allowing you to decompress.
Ameer Farooq 32:43
I'm curious now that you've done this really deep dive and you have whole career to look back on. I wonder if there's things that you wish you had known about dealing with stress early on in your career. I wonder if there's things that now you wish you would have known early on in your career. Would you have changed anything in terms of how you approached your career and dealing with stress?
Janice Pasieka 33:09
Yeah, you can always reflect back and say, "I should have, would have, could have," but you know, I don't know if I could say that I would have changed anything because my career has been successful and I really enjoy what I do. I think - right from as a resident - intracareer exercise was very important to me. I think that discipline came from being a varsity athlete at Western. I always - even as a resident - incorporated squash and exercise into a busy residency and I continue to do that. When you started your career that started to slide a little bit because all of a sudden you had new pressures. I know the residents don't believe this, but it can be harder to balance your life once you become faculty, because there's other pressures. And I had to revisit that and bring exercise and squash and all of the discipline that I learned as an athlete back into my day-to-day routine. And as I said, I would have taken up things like yoga and learned more about mindfulness and how to calm things down. Earlier in my career, yeah, there were things that I could have changed, but I'm not going to regret anything. But I just encourage everybody to really reflect on being yourself and your personal happiness. This is so important to be successful.
Ameer Farooq 35:13
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.