Part 1 : Finding the Calm in the Storm

Episode Introduction and Guest Welcome 0:00

Welcome to a special Heartline Echoes episode where we revisit some of the most impactful conversations from Heartline changemaking in healthcare. This rerun isn't just a replay. It's an opportunity to reflect, reconnect, and reignite the ideas that continue to shape the future of healthcare. Whether you're hearing this for the first time or returning for some fresh insights, let's dive back into this powerful discussion. Enjoy. Thanks for listening to Heartline, Changemaking in Healthcare. If you're ready to deepen your own inner work or want to bring these conversations into your organization, visit andreaaustinmd.com.

You'll find resources and ways to connect with me for coaching, speaking, or consulting. Don't forget to subscribe, leave a five-star review, and share this episode with a friend or colleague. Until next time, keep following your heartline. I am so excited to have Dr. Leslie Koenig, a board-certified emergency physician, Afghanistan combat veteran, COVID frontline hero, and creator of the Stress Relief Survival Guide. In the emergency room, Dr. Koenig accumulated an arsenal of techniques that work quickly and efficiently to lower stress.

Through her military service, fast-paced career, work through the pandemic and her personal journey, she has helped thousands through the worst days in just minutes. She's born and raised in the Midwest and she loves being a mom and wife, loves to exercise, travel, meditate, and is constantly seeking new hobbies.

Origin of the Stress Relief Survival Guide 1:32

And I am very excited to have Leslie on our podcast because we actually went to the same residency program. Leslie was a fourth year resident when I was an intern, but we actually didn't really get to know each other very well because I can say this, I am old enough that in the Navy there was not a categorical intern here. So I was a transitional intern. So I only did a month of, I guess I did two months of emergency medicine. I was able to work the system a little bit, but I really didn't get to know Leslie very well, but I know several people that know Leslie very well.

So I'm very happy to have you here. So awesome to be here and to see you again. So I have such fond memories of the other women in our residency program. So you're definitely a standout. Oh, that's so sweet. Yes. I got to get Crystal on the podcast. I haven't talked to her in a long time. Yeah, she's been busy too. Yeah, there's a lot of really cool people. So we share that military background in common and both emergency physicians And I think I want to start with your book, The Stress Relief Survival Guide.

That's amazing that you're a published author. And I'm curious about what is your workbook and how did you come to make that? Oh, such a great question. And I'm so happy that you know about it. I'd love to get it out there. So I'm happy to be on this podcast and to share all this with you. So the stress relief survival guide stems from originally just a Facebook post. When COVID hit, I was one of the first people exposed to it when we didn't know what was going on. So I was actually at a friend's wedding, I was about to walk down the aisle as a bridesmaid when I was told you need to go into quarantine right now you've been exposed.

And I was absolutely horrified and instant stress in that moment. And I literally left my friend's wedding before I could go down, like 10 minutes before it was supposed to start. So I went home into quarantine and was just thinking of how do I turn lemons into lemonade? And I started to think about how I was dealing with the stress of being exposed to COVID, having built up this arsenal of tools. And I started and I was like a lot of people are starting to wonder what's this Kobe thing a lot of fear when it first happened.

So I started off as a Facebook post and I just couldn't stop writing it just almost wrote itself. I recognized how I had built all of this through years and years and wanted to share it with people who are going to be facing something very very quickly and not a lot of time to prepare. So I just kept writing and writing. And again, it was one of those things that just brought itself. I put together as much research behind it as I could. And it just kept going and going. And then I put it out there for free as a PDF download.

And people wanted a printable copy to share with their residents to give to friends. And that is how it ended up on Amazon.

The Battery Technique for Stress Relief 4:49

So that's where it really the origination story of the Survival Guide. That's amazing. So obviously we want our listeners to buy a copy and support your work and I believe it's extremely helpful as well. What is one technique that you come back to over and over again and that has been very helpful for you? The technique that is probably one of my favorites and easiest to guide someone through is called the battery technique. And it's one that came to mind while I was at work and I've used it with a handful of patients, including patients who came in with suicidal ideation.

And all you need is a pencil or a pen and basically you pretend like this is a battery where you assign one end a positive side and one end a negative side. And it is a bit of a multiple techniques all in one. And it's designed to help you stay with your thoughts and to see what the weather is like in your mind. So say, for example, you come home and you're upset and you don't quite know why, or even if you're at work and you don't quite know why, just pick up a pencil, assign the pencil kind of as a battery, one side is positive, one side is negative, and just look at your thoughts.

So as you're holding it, you become mindful of what's going on in your mind. and you can say, okay, I just got home and I'm stressed because I need to start dinner. And that kind of gives you maybe this negative feeling. So you can move that to the negative or unpleasant side of the battery. And then you can say, okay, okay, recognizing grounding in that seeing the mind state. And then just again, continually as you re-examine the mind, go back to the neutral and holding the battery here. And then reexamine like, well, okay, but the good news is I'm home.

So that's a positive mind state. That's a positive thought. That's a positive emotion. And you move the pencil to the positive side. And you continue doing this until you feel a bit more stable. And even if you're just holding a pencil kind of in a neutral state, the point is you're still examining the mind and you're still can appreciate why am i stressed and you can move into other practices maybe in a bit of a negative state but i'm home i want to focus on the positive so it can become a bit of a gratitude practice at the same time and the reason is called the battery technique not only because there's a positive and negative side but the fact is when you do this you're charging your own mind you are sitting in a state where you are recharging you're looking you're examining and you're grounding in the present moment, which is always a good place to stay and be examined.

So that's why as you go from positive negative and you examine, you are charging yourself, charging your own battery while examining what's going on. With emergency medicine physicians and physicians in general, I still feel a lot of resistance to concepts like this, meditation, mindfulness, some of the other things we're going to talk about, integrative medicine. How have you found ways to make this more accessible, approachable to emergency physicians and other physicians? That is such a good question and such a great observation.

And I myself was one of them. When it comes to meditation and integrative medicine, it took me a long time to get to it. But just like any truth out there, the truth will make itself known. And the thing about meditation I resisted was I just thought, I am too busy in my head. It is not for me. That's for all those people who can calm down. I am not one of those people. I'm a type A go-getter. I don't have time for that stuff. And whenever I did try it, I felt like a complete failure about it, which as a physician where we don't like sailing, we don't like not feeling like we're doing something well, which I think was my mistake.

What I came to understand about meditation is that it is not at all about clearing your mind.

Reframing Meditation for Busy Physicians 8:50

Meditation is about investigation for me and being present with what is. And one of the breakthroughs I made with meditation was understanding that as I sat there and paid attention to something as boring as the breath, when i would my mind would wander as it does when i would start rehashing the past or rehearsing the future but then i would in that moment you know light bulb oh my mind is wandering back to the breast that was meditation so every time you realize oh i failed that is your success And I did not know that initially.

And as one meditator has said, it's like a bicep curl for the brain. Every time you return and you recognize, oh, my mind is, quote, not clear, I need to go back to whatever it was. That is where all the research shows your neuroplasticity benefits, your mental health benefits, and the physical calming ultimately follows with that. So I think just having the right mindset and the right perspective on what meditation is so that you feel like you're doing it well. I think for a lot of us type A really go get or want to be successful physicians.

If you understand that it opens a whole new door to what's possible. So how long have you been meditating? It's hard to say because I fell into it slowly. It started when I was doing more visualizations to help combat my insomnia as a circadian rhythm disrupted shift worker. As you know, I had a lot of trouble sleeping and that's how I started doing it was visualizations of like, you know, a calming thing. I would visualize it was a rainbow. technique where you kind of go through red orange yellow and at the time I was like gosh is this so stupid that this works on me and I was almost ashamed to admit it that that this technique which is a guided visualization helped me fall asleep but that's what I needed I just wanted to sleep I was exhausted I had a crying baby I was working shifts all over the place nights weekends holidays and I was so tired And these meditations were so boring that they helped me sleep.

So I loved them. So I did the guided visualizations for about a year. And that was when I had a brand new baby who is now seven. So that's when it started about seven years ago. And I got bored with that. As I do, I get bored with things. I want like, what's the next thing? What's the next thing? Let's go. And I started looking for more. And then I came to realize what meditation was. But there was some start and stops. I have to say, but I once I realized what it was, and that my failure was actually a success that totally was a game changer, and I am now becoming a meditation teacher.

Tell us about that. What program are you doing and what does that type of training involve? So I just started about four weeks ago. There are multiple different programs. I initially looked at doing NBSR or mindfulness based stress reduction. That involves a lot more than what I was looking to do, which is a fantastic program. I have taken an NBSR class. So highly recommend if anyone wants to get into that's a great way. My program is through the past. And the reason I know about that program is because I did a meditation retreat with that company.

That entails is we do readings on meditative techniques, meditative philosophy, meditative practices, and this class is designed to become a teacher. So that's kind of the foundation. But mostly we are now learning about different meditative styles. Because when we say meditation, It's a little bit like sports, saying sports, like, OK, I am a sporty person. So that there's baseball, there's football, which sport are you practicing? And the one that I do is insight meditation, which involves different kinds.

There's compassion meditation. There's insight meditation, like insight in there. There's breath practices, body practices. So right now I am focusing on leading people and just practice. It's kind of public speaking. It's learning how to become a public speaker, but a meditative teacher instead. And we were, I know we practice in our different online class with pods. So I have three pod mates and we practice leading 10 minute techniques or 10 minute meditations with each other. That's awesome. Yeah, for our listeners out there, I started meditating about, I don't know, four or five months ago.

And for three months, I was really good.

Becoming a Meditation Teacher 13:12

I did it 10 minutes a day religiously in the last couple of months as life. happens, I've kind of fallen off the wagon a little bit. But I will say what I noticed is, I think it's the Viktor Frankl between stimulus and response, you know, lay the space and butchering the quote, but you get the idea. That was always extremely elusive for me. And I think part of it is our training, especially in emergency medicine, is to react so quickly. And you're always on, especially during training, they kind of keep you on edge that you need to be careful.

You need to make sure you're not making a mistake. Don't under triage somebody. And that kind of hypervigilance and reactivity started to bleed out into other areas of my life. And meditation really sounds stupid, but it actually helps you create. It's like, I never understood that stimulus response. How do you create the space? I think meditation is one of the most effective ways and maybe the only way. I don't know how else to really lengthen that space. That is so true and such great insight.

Yeah, I love that quote. And Viktor Frankl has such an amazing story about how to approach life in general. And the thing about, I totally agree, the hypervigilance that we're trained to have as an emergency physician, and especially in our residency, I remember our attendings telling us constantly be on edge. You know, they were training us to go deploy to Afghanistan and who knows where else. So we were trained to always be on edge and if you weren't you're like a bad doctor and you're made to feel like a bad person if you are not hyper vigilant and always reacting and always making decisions and busy busy busy.

And that blood into how I treated myself was that whatever approached me in life I felt like I had to immediately respond. You know, there's no time to sit and think about why am I stressed? There's no time to sit and think about how do I treat my family better? I'll just do it later because I need to just do something now. I need to get dinner on the table. And the easiest way to do that is my old bad habits of, you know, yelling or getting reactive, which ultimately, as I came to realize, was making me unhappy.

And sitting and recognizing that made such a huge difference. It's hard to describe the difference that meditation can give you once you get into it. So I want to talk a little bit about how you're using heart rate variability. I think we're both tracking our heart rate variability and I am a very strong believer that this is the actual fifth vital sign, not the whole pain BS that we were taught in residency. that heart rate variability is a really key indicator of our overall health. And just for the listeners, if you haven't heard me go through this before, heart rate variability, and most of our listeners are doctors.

So when you look at an EKG, the R to R interval naturally varies beat to beat. And so when we say heart rate variability, we're looking at how much that varies beat to beat. And this might seem counterintuitive at first, but having high variability is actually good. And what heart rate variability actually reflects, which is super cool and unique, is the balance between your body's response to sympathetic and parasympathetic response.

Heart Rate Variability and Recovery 16:48

And so having a high heart rate variability means that your parasympathetic response is good, is robust, and is able to react well to when you're having a sympathetic surge. That's the primer for heart rate variability. I want to turn it over to Leslie to talk about how you're measuring it and why and how it's changed through your practice of meditation and other wellbeing activities. Heart rate variability tracking has definitely changed the way I live my life 100%. The way I look at heart rate variability is it's almost like a seesaw where you can have sympathetic as being one person and parasympathetic being the other person on the seesaw.

And when they're well balanced, you can have a proper seesaw effect or even just kind of a little bit of variation there. But if you have that sympathetic person who is weighing heavily in your life, there's going to be no variability because you're constantly and sympathetic and a parasympathetic can exert its effects. And I noticed how my circuit and rhythm activity and it would tell me what my heart variability was at night and I recognized the minute I got my ring because of how my sleep schedule is as an ER physician.

It was all over the place and my score was completely in the toilet and whenever I work, I do all nights now to try and maintain some semblance of normalcy. It just drops and as you say, it should be the fifth vital sign. It's almost like perceiving your life always in tachycardia, which is not good. And so it's changed how I plan to move forward in my life, which is more vacation, better sleep, continue to meditate. And I am now focused on doing an integrative medicine fellowship so that I can have more ownership of the schedule.

So a few things that I've noticed with my heart variability that does increase it, as I mentioned, was vacation, a better circadian rhythm. When I did a meditation retreat, it went really high and stayed high for about two weeks. And I did a water fast for a week, and that was the highest I had ever had my variability be. It was in the hundreds, which I was like, I've never been that high. It was with a water fast. Wow, I have not reached the 100s. My highest has been in the 60s, and I've been sustained in the 60s for the last three months.

It's like my new average. And I'm pretty stoked about that because last winter during COVID surge, ton of circadian disruption, which is the way my schedule was, I was in the thirties to forties pretty regularly. And sometimes even down into the twenties, I dipped down into the twenties when I had COVID and even just like some days that, you know, were really stressful at work or sleep was messed up. I really encourage our listeners to consider a wearable device. I'd be happy to message anyone. I use a whoop.

Leslie mentioned Aura. I'm not receiving any money from whoop. I wish I was, but I'm not. No money here. Yeah, I am curious. I've been thinking about switching to the aura because I don't really like having a strap around my arm because I already wear an Apple watch. How have you found the durability of the ring and like just like wearing a ring? Oh, it's so easy. I wear it pretty constantly. I wear it at work. I wear it going to the gym. And why I wear it running, I go to the gym, I do weight lifting.

I don't take it off. My husband actually wears it in place of his wedding ring. Now he wears it to the gym as well. I wore it on my recent hike in the mountains. It died on the fourth day. So the durability has been fantastic. I have not needed to replace it. I got an upgrade. Now this one actually tracks my pull socks. That's been fantastic. Yeah, that's really cool. I think it was actually on a call with a friend last night who's also an emergency physician and we actually had lost touch and we hadn't spoke for about 10 years.

I'm so glad we reconnected and she's actually married to a prior professional hockey player. And she's going through a similar thing. I think most of us have gone through. I mean, 70% of emergency physicians experience burnout at some point in their career. And I would say that's probably under reported. I think everybody pretty much goes through it. Maybe there's like 10% of people that are truly resistant to it. And we should certainly be studying those people. But what we came upon last night is We should, as emergency physicians and physicians in general, especially specialties that involve quick reactions of physicality to what we do, which I would put emergency medicine, a lot of the surgical specialties, critical care, a lot of those specialties into that, we should be looking at ourselves as elite performers.

And I think by not looking at ourselves as elite performers. It leads to a lot of really bad things for us. We don't pay attention to our nutrition like a professional athlete would. I mean, professional athletes are tuned into this. Heart rate variability is old news to them. They've been tracking that for at least 10 years, some of them probably 20 years. And I think by not really taking a really focused approach to our own well-being, knowing that we're going to go into these challenging situations.

Most of us are going back to a battery analogy. We're going in at 25%. We're not charged when we're going into these intense situations. What are your thoughts on that? You're 100% right.

Elite Performance, Burnout, and Diastole 22:48

I have not thought of that before, so that is such a great way to look at it, is that we truly are elite performers, and we kind of always have been, but many of us just rely on our willpower and dedication to our careers and our altruistic nature to carry us forward. But the culture of medicine is always changing, and it's so difficult to turn that eye inwards. And we should. Yeah. So that's a challenge to the listeners. Really look at what you do as elite and that you need to invest in your nutrition, in your sleep, the same way that, you know, pick whatever sport or thing that resonates with you, whether it's a gymnast or a pro basketball player, think about how much time they spend on what they put into their bodies and their sleep and their recovery.

And that's something I've talked a lot about on another podcast called The Emergency Mind is we focus so much on performing. The other side of that is recovery, and we're notoriously horrible at creating space for recovery. 100%. I had a coach tell me this, and I thought it was such a great analogy as a physician, is know the cardiac cycle, their systole, and diastole. And the thing about diastole is it's two thirds of the cardiac cycle. I mean, our own hearts know what it needs to rest. If you're going to go for your whole life, you need to rest and to pay attention to what that rest should look like.

To have that investigation, to give yourself that space and put on your own oxygen mask first. It is so important to prevent burnout, but it's not about just preventing burnout. It's about living your life. You've dedicated so much to your patients and you have learned so many skills that you can give yourself. It just takes that kind of paradigm shift. to pay attention to yourself. You're so used to paying attention to somebody else that it's your turn. You have to put on your own oxygen mask first, get yourself into that diastole, rest, recover, reevaluate, find what your goals are and align your values to what your behavior is.

So we're going to leave it right there for part one of my interview with Dr. Leslie Koenig. Please listen next week to part two. We're going to get into a discussion about some of the system-wide changes that need to happen to support physician well-being. Please check out Dr. Kenning's book, Stress Relief Survival Guide, which is available on Amazon. Her website is stressreliefsurvivalguide.com, and you can join her Facebook group, which has tips on stress relief. That's Stress Relief Survival.

You can follow her on Instagram at Stress Relief Survival Guide, LinkedIn, Leslie Kenning, and also available on Twitter. at stress relief. So lots of ways to connect. I hope you all have a great week and please join us for part two of my conversation with Dr. Leslie Koenig next week. Welcome to Heartline, Changemaking in Healthcare. I'm your host, Dr. Andrea Austin, a board-certified emergency physician, physician development coach, and educator. After years on the front lines, I've learned that real change in healthcare starts within.

Each episode invites you to explore the inner work that unlocks clarity and bold leadership, because healing systems through changemaking begins with following our heartlines. This podcast represents the views of the host and guests. It does not represent the views of any entity we work for or with. It is also for informational use only and does not replace any professional advice, including medical or psychological. If you are interested in unlocking your true potential, reach out to me. If you're an organization interested in supporting the wellbeing of your people, I'd love to connect on innovative solutions.

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