Dr. JB: Hi, everyone. Welcome back to the Hope4Med podcast. I am your host, Dr. JB, and today’s featured guest is Dr. Ni-Cheng Liang. She is a mother, a cancer survivor, mindfulness teacher, and award-winning pulmonologist. She is a leader and international speaker on physician wellness, mindfulness, anti-racism, integrated and pulmonary medicine who has taught courses, led retreats, and design wellness curricula for the past 10 years. Welcome to the show.
Dr. Ni-Cheng Liang: Thank you so much for having me on.
Dr. JB: So, I love beginning these episodes by learning more about you and your story. So, could you please share with my audience your origin story?
Dr. Ni-Cheng Liang: Yeah, absolutely. I think it really starts where I was in pulmonary fellowship back over 10 years ago now, and I was diagnosed with a very aggressive form of breast cancer. It was very sudden, out of the blue. At the time, I had shortly finished breastfeeding, and thought it was just a regular clog ducted, but knew I should get it checked out. And the ultrasound results were really worrisome, and almost immediately I was ushered into the biopsy. And ironically, I had a poster discussion session to give over at the American Thoracic Society meeting. And so, the day after the biopsy, I flew over to Denver for that academic presentation, not thinking much of the biopsy.
And then that Sunday, I’ll never forget, I received a call from the radiologist that did the biopsy, and she told me in the middle of lunch, that it was consistent with invasive ductal carcinoma. And I broke down right there in the restaurant, luckily, I was surrounded by friends from residency, and the tears and the fear, it was probably the most scared I had ever been in my entire life, because all I knew at that moment was that I had breast cancer, didn’t know what stage, what the treatment plan was going to be, if I were going to survive, how long that would look like. So, there’s just a lot of unknowns and uncertainty.
Flew back to San Diego that very same day, because I knew immediately, I wanted to be with my loved ones, not knowing how much time I had left. And luckily, over the next couple of weeks, the results from more biopsies, more scanning, I enrolled in a clinical trial, and basically underwent five months of one of the toughest regimens for breast cancer, chemotherapy, as well as three different surgeries over the course of a year. And I decided right then and there also to take some time off.
So, I took the year off from my fellowship to really work on healing, both inside and outside. And it was through that traumatic journey, this experience of feeling like my body was betraying me, and yet, at the same time, having to learn to trust it again over time as it healed, really reshaped the way that I care for myself, and also how I practice medicine. And it’s through that that the mindfulness came in.
I was at a Cancer Survivor Day for the cancer center that I received my care at, and it was Dr. Steven Hickman who was the founding executive director for the UCSD Center for Mindfulness that introduced the concepts to the cancer survivors at the time. And what he was saying resonated very deeply, because I am a born and raised Buddhist. But only dabbled in contemplative practices here and there, dabbled in yoga practices here and there, all of this before cancer.
And it wasn’t until cancer that I really developed certain specific self-care strategies, one of them being mindfulness, to be able to build a scaffolding of sorts, of support for myself. So, that truly, I could take care of others. So, we can’t take care of others unless we care for ourselves. And what that looked like for me, learning the hard way was these self-care measures that I needed to prioritize and keep in place. And so, that’s how I came to mindfulness.
Dr. JB: Wow! So, now you are currently in remission?
Dr. Ni-Cheng Liang: Yeah, luckily, yes.
Dr. JB: Congratulations.
Dr. Ni-Cheng Liang: Thanks, thanks. 10 years was just in 2021, so thank you.
Dr. JB: And here you are, you’d gone through all these hoops, through medical school, residency, fellowship. And you’re like, okay, I’m about to be finished, and I’m going to go and become this attending, and bam! You get this diagnosis. And so I understand, you said that you were a new mom.
Dr. Ni-Cheng Liang: Yeah.
Dr. JB: And so how did this experience affect…? I know you mentioned how it’s changed the way that you practice. But what about like your life, your home life, you’re a new mom, how did you manage all that?
Dr. Ni-Cheng Liang: Luckily, my father who had moved from the East Coast, and had just recently retired was available for us to help out with childcare. And I was so grateful for that, because I had chemo days where I was laid out for most of the day, from the exhaustion, and just being nauseated, and just feeling not great. So, I’m super grateful that my dad was able to care for my then, only child, but now eldest at the time. To allow me to truly take the time that I needed. Yeah, so that’s how I did it; it was family help support.
Dr. JB: Wow, and so you said you were born Buddhist?
Dr. Ni-Cheng Liang: I am a born and raised Buddhist, yeah, I’m a practicing Buddhist.
Dr. JB: And a lot of these elements in mindfulness, in terms of meditation and things like that are part of Buddhist religious practices, no?
Dr. Ni-Cheng Liang: Yes, they are. So, mindfulness has roots in Buddhism, but Jon Kabat-Zinn, Biochemist Phd, from University of Massachusetts, Developed Mindfulness-Based Stress Reduction, based off of a lot of the tenants of what’s found in Buddhist philosophy for instance and Buddhist practices. And so, you don’t have to be Buddhist to practice mindfulness. So, I think that he’s really done a great service to bringing mindfulness to the West, in a way that’s more accessible and that can benefit, really all humankind.
Dr. JB: And so, with these practices—or walk me through how you incorporate mindfulness in your day-to-day life.
Dr. Ni-Cheng Liang: Sure. So, mindfulness is paying attention on purpose to the present moment without judgment. And then that aspect of compassion and warmth towards self, oftentimes gets dropped in the definition of mindfulness. But most recently, I have come to the understanding and also the intentional inclusion of that warmth and compassionate attitude, towards self when practicing mindfulness.
And so, how it looks in my day to day is that, I wake up, I do a mindfulness practice, usually there’s some loving kindness melded into mindfulness practice. It’s usually based off of awareness of breath, sometimes a little bit of body scan, where I’m noticing different bodies sensations. And then throughout the day, I incorporate mindfulness when I’m with my patients.
And I think that’s what’s shifted my relationship with practicing medicine. Is at these micro moments of mindfulness, where it could be as easy as noticing their breath, when I’m listening to lung sounds and then breathing with them at the same. So, there’s almost like a co-regulation of breathing in community for the couple of seconds it takes for a lung exam.
And then also I incorporate a walking meditation practice during my lunchtime hour. I’ve given myself permission to actually take a lunch break, and that usually looks like eating mindfully. So, I turn off all the screens, I put my phone away, I eat in silence, and I truly notice, look at, taste, enjoy the food in a mindful way. And usually, it’s much slower than if I am not eating mindfully.
And then I go for a walk. So, I take a couple laps around the parking lot, and I notice, luckily, we’re in San Diego, so I’m able to do that most days of the week, noticing nature, sometimes I notice butterflies, there’s flowers that are starting to bloom. So, I make it a very intentional practice to do walking meditation, while noticing nature. And then that helps me reset for the next half of the day, so that I can show up with renewed energy and freshness for the next 10 to 12 patients. And so, that’s really been helpful to interweave mindfulness into my practice of medicine.
Dr. JB: And I could see how engagement and practice like that could also help you feel more grounded and more connected to life in general.
Dr. Ni-Cheng Liang: Yeah, absolutely. That’s one of the purposes of mindfulness, if you will, is to have the mind and the body at the same place at the same time, to fully be present for your present moment experience, as opposed to future living, catastrophizing, that many of us in medicine are so good at. We are expert catastrophizers, because we’ve been trained to do that with worst case scenario, differential diagnoses, on behalf of our patients.
And then also to avoid and to not be living in the past so much with regret. Of course, these are all very normal human behaviors, our brains are hardwired to look for problems as a survival mechanism, looking for threats as a survival mechanism, but here in the 21st Century, it doesn’t serve us as much to be constantly hyper vigilant in that way. And so to relax, or to really melt into the moment of our lives, truly gives us the opportunity to savor and enjoy life, even when it’s not peachy keen. It’s all opportunities to practice mindfulness, and to practice being present with what is.
Dr. JB: So, before you had this diagnosis of cancer, going back to your childhood religious practices, the Buddhism. Were you practicing Buddhism then?
Dr. Ni-Cheng Liang: Yes, yes. So, we were going to temple pretty regularly, we were reading and reciting and chanting mantras and sutras. But I had not really delved into, or committed to a meditation practice prior to the cancer experience interestingly. And people believe that, especially in Buddhism, there are certain causes and conditions that occur in your life to advance your practice of Buddhism, or to incorporate lessons learned. Like, I wasn’t ready for the need for contemplative practice before then, I wasn’t open and receptive yet. And it was the causes and conditions of having undergone breast cancer that opened me up to truly try to embody and really commit to incorporating it.
Dr. JB: Because the reason I bring that up is, I am just curious to know that though…So, if we go back to when you were going through training and you were practicing Buddhism, you went through these hoops, did you ever experience any symptoms of burnout? Or did Buddhism prevent you from experiencing that? Does that make sense, my question?
Dr. Ni-Cheng Liang: Yes. So, I like to say that my body went through a physical burnout. That my body was telling me, if I continued to go 200 miles an hour, that I would literally put myself into the ground. So, there was probably, looking back a component of emotional exhaustion that was there, that was manifesting very physically. And then in terms of depersonalization, I don’t think I had much of that, but I could definitely see myself, had I not literally been stopped in my tracks with the breast cancer diagnosis, I could definitely see myself going that way.
And then the decreased sense of personal accomplishment, definitely. Sometimes it came up, sometimes there were, especially in critical care medicine, there were really frustrating times of seeming futility and moral distress that occurred. So yeah, I like to say that it was a physical burnout that I experienced, and it was the breast cancer that helped prevent me from mind, body and soul burning out.
Dr. JB: And so today, do you still do a lot of critical care medicine?
Dr. Ni-Cheng Liang: No, actually, I don’t. So, one of the things that I did when I came back to the practice of medicine and fellowship, was to set some safety rules for myself in place. Knowing that I had these tendencies for overextending myself, for over self-sacrificing. Even though I had just come back from breast cancer treatment, those tendencies were hard ingrained in my childhood, they were rewarded in college and med school and residency.
So, my own safeguard, my line in the cement was to not complete critical care fellowship, and really focus on pulmonary medicine fellowship completion. And to this day, I definitely don’t regret that decision, and I’m so grateful that I made that decision for myself. Of course, there’s also some guilt regarding not being in the ICU during the COVID 19 pandemic. But I like to think that as an outpatient pulmonologist and also as a consultant on the inpatient side, taking care of a lot of COVID patients, I’ve contributing in my own way, even though it’s not in the ICU.
Dr. JB: So, walk me through these feelings of guilt, why did you feel guilt?
Dr. Ni-Cheng Liang: Yeah, so seeing my colleagues, my partners on the front lines, taking care of the sickest of the sick, and doing all of these risky behaviors, knowing that there was somewhat a shortage of intensivists, knowing how close I had come to finishing critical care fellowship, I felt like I wanted to help out more, and I felt that perhaps I wasn’t doing enough outside of the ICU, knowing that there was this need. But now in retrospect, now that we’re two years out from the start of the pandemic, seeing COVID patients every day, I don’t think I have as much guilt with regards to that. I’m definitely contributing in different ways.
Dr. JB: That’s right.
Dr. Ni-Cheng Liang: There’s plenty of ways to help to go around in the COVID pandemic, if you’re a physician.
Dr. JB: There are, and there’s non-traditional ways of helping. And through your mindfulness practice that you’ve been engaging in and teaching for, even before COVID, that’s a way of helping, because that’s a release for people.
Dr. Ni-Cheng Liang: Yeah. So, now I’m a fellow at university of Arizona, integrative medicine. And I recently just gave a talk on integrative therapies, and how those can be ways for empowerment for patients who do have long COVID, because now we are seeing more and more people, especially people who are otherwise healthy, suffering from long COVID effects.
Dr. JB: So walk me through, how do those practices empower a patient, or anybody?
Dr. Ni-Cheng Liang: Sure. So, a lot of integrative medicine includes lifestyle medicine. So, we know the pillars of health that we might have counseled patients on, maybe even our own family members on. And those pillars of health are getting good quality sleep ,7 to 9 hours of consolidated sleep a night, exercise, moderate intensity, 30 minutes or more, most days of the week, up to 150 minutes at the minimum. Nutritious diet, so, oftentimes the Mediterranean or Dr. Wild’s anti-inflammatory diet are very healthy for the vast majority of the population, especially in COVID, where there’s such an inflammatory component to it, and then social connection.
So, nowadays with the decrease in numbers of COVID cases, there is more opportunity for in person social connection, but even when we were very much online to prioritize social connection with loved ones. And then something for stress reduction. So the fifth pillar is stress reduction. So, it doesn’t have to be mindfulness, but what is something that resonates with you to help reduce stress, and to prioritize time in your day for that?
So, when patients and really everyone are reminded about the pillars of health, these are actions that you can take right away to help optimize your health and wellness without the use of medications, without the use of classes. Really, these pillars of health can come from within, in terms of what that looks like for you, you get to choose. So, that’s what I mean by empowerment, is that these are very accessible ways to become healthier.
Dr. JB: You know, I really like the word that you had used before. You mentioned about just like melting, into the environment, becoming one with the here and now. I think, I agree with you, for so for so many of us, where we spend a lot of our days thinking about all the things that we wish we had done yesterday, and all the things we’re going to do tomorrow. And we forget about the present, which is the only thing we truly have control over, and the only thing that’s going to pass us by in a second. But it seems like to me, you really focus on being present.
Dr. Ni-Cheng Liang: Yeah, the only time we have is right now, and if we’re not present for it, then we miss out on it. And I think time is one of our most precious commodities as a human being, and there’s a lot of reasons for why there are tendencies to future live and catastrophies and regret. But because our human brains are capable of changing, our capacity for neuroplasticity is really great, we can take advantage of that, and we can be intentional about how we want to spend our time. And if that means that we are more present for more moments of the day, and I truly believe that helps improve our quality of life, and it also helps improve the quality of life of everyone around us. So, our loved ones, the people that we live with, our patients, those that we care for all feel the effects. These are the ripple effects of mindfulness that I like to call it.
Dr. JB: So, I know you mentioned neuroplasticity, and so I want to delve into that just a little bit more, and using an example of somebody who has spent their whole entire life, not really being present. And so, if they’re like okay, now I want to figure out, how can I be more present in the moment? How do they do that? What are some of the first steps that they could take to walk down that path?
Dr. Ni-Cheng Liang: Yeah, so, the intention of wanting to be more present in life is step number one. So, you can’t really be present unless you want to be present, because there’s so many other distractions and ways for you not to be present, especially with screens now a day, right? Between our laptops, TVs and our phones, so intentionality is definitely step number one.
And then step number two is, curiosity. So, being curious about what presence looks like for you in your life. Where would you like to be more present? For working moms for instance, oftentimes it’s, I want to be more present for my kids, or my spouse. And others in medicine want to be more present for their patients. And so, thinking about, and getting curious about where it is. Because ultimately, mindfulness, it oftentimes gets taught as a tool, a tool in your toolbox that you can reach out, and pull out whenever you need to. But really, what we hope mindfulness can do is to get into every nook and cranny of your day-to-day conscious existence. So that you allow mindfulness to melt—using that word again— melt into your lived experience.
Dr. JB: You embody it.
Dr. Ni-Cheng Liang: Yeah, and so, intentionality, curiosity, and then practice. So, you can read all you want about mindfulness, you can go to lectures, you can watch documentaries about it. But unless you actually practice it, you will not really have a sense of what it means to be mindful. And there are so many different apps out there now that you can try for free, so, some of the ones that I like, and some of the physicians that I’ve worked with, and patients that I’ve worked with have really enjoyed our insight timer, 10% happier, calm head space, and because of the pandemic, there have been free subscriptions, and different various free offerings from all of those apps.
And then I have some previously recorded audio practices on my website, www.wakenbreath.org, through freely available, different durations. And then I also have a mobile wellness for healthcare professionals, series of 1-to-5-minute practices. If you just want to dip your toe into practice made specifically for healthcare professionals, maybe it’s in between patients or in between meetings, you can fit in a quick practice. That’s also available on the website.
And then when you’re ready to commit to more, to really allow mindfulness to ooze into every nook and cranny of your life, then you can commit to a mindfulness course. The foundational one is Mindfulness-Based Stress Reduction, it’s an 8 week course with two and a half hour classes every week, with a day of mindfulness. That’s a 6-to-7-hour day of silence, really dedicated to the practice of mindfulness.
And there are other courses out there, but I like to mention Mindfulness-Based Stress Reduction. Because it has such a body of medical literature studied about it. There are over 9,000 articles published in medical literature about mindfulness and many of these studies involve the use of the foundational course of MBSR, or Mindfulness-Based Stress Reduction. So, that’s how you can do it, intentionality, curiosity about where you’d like to see your presence manifest most, and then actually practicing it, that’s how people can get started.
Dr. JB: And something interesting you mentioned was, you don’t have to necessarily commit to 30 minutes or some prolong period of time to engage in a mindfulness practice. It can be as short as a minute.
Dr. Ni-Cheng Liang: Yes. So, there are a couple of different ways that you can incorporate mindfulness. There’s formal mindfulness practice, where you have a dedicated, usually longer proportion of time to practice. And then you have informal practices of mindfulness, some of the ways that I had mentioned before, like taking mindful breaths with your patient, while you’re listening to breath sounds. Or mindfully walking from one room to the next, between patients or from your office to the exam room.
So, different durations, and we know from some of the medical literature that’s published already, that in order for neuroplasticity to come about with mindfulness, the minimum duration of practice is about 12 minutes a day. So, even if you’re not able to commit to 12 minutes a day, just a minute, or a moment of mindfulness, that is still better than nothing. Similar to exercise like standing or walking for 15 minutes, 5 minutes is better than nothing.
Dr. JB: And the 12 minutes, is it continuous, or additive?
Dr. Ni-Cheng Liang: So, it is considered to be continuous, because it does take a couple of minutes for the nervous system to settle down a bit. But if you can’t get it in continuously, you can try to break it up into different chunks of time, and really make your practice your own. Like the best practice for mindfulness is the practice that you’ll actually do.
Dr. JB: That’s right, that’s right.
Dr. Ni-Cheng Liang: Same with exercise, right?
Dr. JB: That’s also, right. And with this practice of mindfulness, is this something that you would normally just do by yourself? Or is this something that you can do with a community for other people? We’ll start with that question.
Dr. Ni-Cheng Liang: You can do it either way. Oftentimes, it’s actually very helpful to be part of a mindfulness community. So, I did found the Mindful Healthcare Collective March of 2020, right? When things started getting shut down with quarantine, and we have weekly events that are really meant to build community. As one of my colleagues and mindfulness contemporaries also Dr. Zoom VO had said in one of his sessions that a mindful healthcare collective is kind of like a professional Sangha. And this word Sangha means community in Buddhism, and so, traditionally in Buddhist practice, you have a Sangha where you can meditate together, because the strength of meditating and community and the experience brings a richness, an interconnectedness that is at a whole other level than if you were practicing individually.
So, I highly recommend people, if you’re interested to, yeah, definitely practice on your own, on your own terms, but then also join a community, and it doesn’t have to be an in-person community, but an in-person Sangha is really powerful as well. The energy really just shifts, and it’s a different experience. And right now. there are plenty of different ways that you can practice in community online as well, besides the mindful healthcare collective, there’s UCSD, Center for Mindfulness, where I used to be executive director.
They have daily practices offered online in community, as well as the center for mindful self-compassion, where I sit on the board of directors, and they have week, they have actually daily offerings of the circle of practice, where you can go online and join an international community and practice together.
Dr. JB: Is this done by Zoom?
Dr. Ni-Cheng Liang: And this is done online by Zoom.
Dr. JB: So, I remember you had mentioned something about doing or walking through a mindful meditation.
Dr. Ni-Cheng Liang: Yeah.
Dr. JB: I’m good.
Dr. Ni-Cheng Liang: I’m happy to do that.
Dr. JB: I’m game.
Dr. Ni-Cheng Liang: All right, okay. So, I bring out bells because the bells are a very readily accessible focus of attention, we pay attention to the beginning and end of practice, and that is what the bells signify. And instead of striking the bell, or hitting the bell, the late Thich Nhat Hanh, one of the greatest mindfulness teachers of our generation, a Buddhist venerable mentions that when we ring the bell, it is like an invitation for the bell to sing. As opposed to striking or hitting the bell. And so, I really like that terminology, that invitation of the bell to sing or to sound. So, without further ado, we’ll go ahead and get started.
Dr. JB: Okay.
Dr. Ni-Cheng Liang: So, inviting you to close eyes, if it’s safe for you to do so, or lowering your gaze if you’re inches in front of you. Begin by noticing the points of contact between you and your environment. And perhaps that is simply noticing the support of the ground beneath your feet, the support of the chair, or whatever it is that you’re sitting upon.
Allowing yourself to simply ground into settling into this moment. Giving yourself permission to leave everything that came before, and everything that is to come at the door. Giving yourself permission to fully arrive in this moment, where the mind and the body can be at the same place at the same time.
And next, I invite you to rest your attention upon your breath at the nostrils, noticing the sensations of breathing at the nostrils. Noticing the in breath, the out breath, and the pause in between. And as thoughts, emotions or other body sensations come and take your attention away from the breath, you can acknowledge that, acknowledging that mind wandering is part of the human experience, and very normal.
But you can choose to bring your attention back to the breath at the nostrils, that this noticing of mind wandering and bringing back to the original focus of attention, is the moment of mindfulness, is the practice of mindfulness. Simply resting your attention on the sensations of breathing at the nostril. And then as you’re ready, shifting attention to the back of the throat, noticing how the breath feels at this new location. And if your attention has drifted, simply noticing that and bringing your attention back to your breath at the back of the throat.
And inviting you as you’re ready to move your attention to the chest, noticing your chest rise and fall with every breath. Noticing the felt sensations of breathing at the chest. The expansion and the relaxation phases of every breath and what that feels like in your body, at the chest.
And then as you’re ready, inviting you to shift your attention to the abdomen, noticing the inflating and deflating of the abdomen as you breathe, not trying to change your breath in any way, but simply noticing. Noticing this natural process that occurs even when you’re not thinking about it. And then as you’re ready, I invite you to choose and to notice, where do you feel your breath the most? Inviting you to rest your attention there, on where you feel your breath the most. So, engaging in curiosity and making a choice.
And if you notice your mind wandering, simply notice and bring your attention back to your breath, where you feel it the most. Knowing that your breath can be an anchor of attention for you, at any time. And blinking, open eyes, letting the light back in, taking a moment to notice how you feel now, compared to just a few minutes ago. So, Dr. JB, how do you feel now compared to a few minutes ago?
Dr. JB: I feel so relaxed, it’s so interesting, because before I started this, I was having a lot of tension. And I through pieces over on the left. And halfway through, I was like, “Oh, it doesn’t hurt so bad.” So, I experienced it right here and now, the effects of this meditative practice.
Dr. Ni-Cheng Liang: It’s, thank you for sharing that, it’s interesting that you said I experienced it, right? Because there actually is really no right or wrong way to experience mindfulness, because what your experience is in the moment, is always the right way. Even if your mind is wandering, the fact that you notice that, is the right way. Even if you notice pain, that is your present moment experience, so that is also the right way.
I will say though that, for people who have active suicidal ideation or who have very severe untreated traumas or anxiety, or depression, that they work carefully with their healthcare professionals, if they are interested in practicing mindfulness. Because there are some potential harms in retriggering of some of these symptoms, especially if intrusive memories or intrusive thoughts come into play, exacerbating some of the symptoms.
Dr. JB: That’s a really good point, I didn’t even think about that. Very good point. Wow! I am so lucky to have been able to engage in this exercise with you, it was really wonderful, really wonderful. And so, if my listener wanted to find out more about you, and get in touch with you, how can they do so?
Dr. Ni-Cheng Liang: Yeah, thank you so much for having me on, and thanks to all the listeners for practicing with us today. You can join us at the Mindful Healthcare Collective, it’s www.mindfulhealthcarecollective.com, and we have a Facebook group of over 2,400 international healthcare professionals available for you. So, please join us, and then for the audio practices that I guide, you can check out my website @awakenbreath.org.
Dr. JB: Perfect. And do you have any pearls of wisdom you’d like to leave my listener?
Dr. Ni-Cheng Liang: Yeah, absolutely. So, if you’re interested in prioritizing your pillars of health, think about what that would look like for you, personalize it to you and your needs. And particularly if you want to learn more and practice more about mindfulness as one of your modalities for stress reduction, simply try it, try it for however long you’re able to, even if it’s just a moment of mindfulness in a day. Because that sets the path, that sets us up for a shift in the way that we relate to stress that is planting the seed. And so, be curious about where it takes you, and how it blooms.