Heart to Heart
Date Published: June 25, 2021
Anu’s story begins with a pulse. She’s 12 years old, holding her grandmother’s wrist, feeling the heartbeat’s rhythm—bounding or thready, slow or fast. “I was so taken by how much you could learn from touching someone, feeling the rhythm of their life, literally,” she recalls. Now a cardiologist at Mount Sinai, Anu Lala, MD, cares for patients with heart failure. Her work often places her at the border between life and death, which has challenged her to think deeply about questions both clinical and spiritual. In this conversation, Dr. Lala reflects on what she’s learned about uncertainty, healing, purpose, and what it means to live a good life.
Anu Lala, MD, is Assistant Professor of Medicine (Cardiology), and Population Health Science and Policy at Icahn School of Medicine at Mount Sinai. She is also Deputy Editor of the Journal of Cardiac Failure.
Dr. Anu Lala: 00:00
I think when you align yourself with what is, then there's room for acceptance to flow in. And when you accept what is, then you recognize the opportunities in that given situation.
From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm Jon Earle. My guest today is Dr. Anu Lala. She's a cardiologist here at Mount Sinai. She works with patients who are suffering from heart failure, which is not a term that she likes, and we'll talk about that. But the reason why I wanted to have her on is because in addition to being a great doctor, she's also a master at guiding patients through what can be one of the scariest, most uncertain times in their life. These are patients who, like I said, have a heart that's not functioning properly, that are sometimes waiting for transplants for months on end. And Dr. Lala brings this incredible warm, very spiritually informed sensibility to her practice. And so in our conversation, she shares things that I think are really relevant for anybody—thoughts on living in uncertainty, thoughts on purpose, the things that working at the precipice of life and death as she does bring into very clear focus. So it's a beautiful conversation, I really enjoyed having it, and I think you're going to really enjoy listening to it. So put yourself in a quiet place if you can, close your eyes, and listen. Dr. Anu Lala, welcome to Road to Resilience.
Dr. Anu Lala: 01:30
Thank you so much for having me. It's exciting.
So I want to start out with a question that I'm going to borrow from a favorite podcast of mine called On Being. In the beginning of every episode, Krista Tippett, the host, asks her guests about the spiritual background that they have. So I'm just wondering what was the sort of spirituality that you grew up with?
Dr. Anu Lala: 01:50
Thanks so much for asking. I think my spiritual upbringing has a lot to do with where I am today. I grew up in a Hindu household. I consider myself Hindu. But what I loved about how our parents raised us was from the very beginning, we were taught that all religions say the same thing in different ways. And I also went to a school, it's called the Swami Vivekananda Vidyapith. Swami Vivekananda was a great philosopher, spiritual teacher, who also emphasized the universality of religion and really had more of a focus on spirituality than on rituals and belief systems. And so I thought that that was so empowering. I know it's a long answer to your question, but that's my spiritual background or upbringing.
The idea that we're all connected, that we're all similar inside, is very much integrated into your work—this is now jumping ahead a little bit—as a cardiologist here. Can you talk about that connection?
Dr. Anu Lala: 02:56
I've thought a lot about this. I think about what is it that enables a connection between two people and particularly in the vulnerable space of where a patient is coming to a physician with a problem or with a challenge. And I think the connection that is afforded is based on empathy. There's a distinction between feeling sorry for the other person or for the patient who's going through a particular ordeal or faced with a particular disease process, and recognizing the oneness in human suffering and joy. And so I think that empathy is so critical. And what underlies that empathy is the recognition that we are all ultimately the same.
You told me something fascinating when we spoke earlier and it's that a heart from any patient regardless of their background, can sustain life in the heart of a patient from a completely different background—different gender, different ethnic background. That blew my mind. I mean, the heart has no shortage of spiritual connotations, but that is a very powerful one.
Dr. Anu Lala: 04:06
Yeah, absolutely. I was just going to say that. If that's not a direct manifestation of oneness, then I don't know what is. And I remember so distinctly being in training, I was in Boston and I went for my first heart transplant surgery to observe, and without disclosing the actual information, I just remember how the heart that was being given to this particular individual was of the opposite gender, a completely different race, completely different languages spoken. And yet she woke up the next day full of life, really, restored. And I think that is just the most profound example of oneness and how we're just the same.
When did you realize that you wanted to be a healer? Not just be a doctor, but do the work of a doctor?
Dr. Anu Lala: 05:03
I don't know if I thought about it that way, quite frankly. I loved the idea of serving as an instrument to heal. And I first knew that I wanted to do this, I think, when I was a young kid. My father is a cardiologist, and my grandmother was visiting from India. I think I was 12 years old at the time, and she actually had a heart attack in our living room. And she emphatically stated that she did not want to go to the hospital under any circumstances. She was in her eighties. And so my father said, "Okay, we'll manage you at home." And so he brought an EKG machine home. He brought aspirin. He brought morphine. And we stayed with her all night. I watched her have nausea and pain, and my father kind of employed us to be a part of the process. And I remember distinctly being told to feel for her pulse. I had my fingers on her wrist, feeling her pulse, and that has become a ritual, if you will, in terms of how I see patients and how I practice. So anyone who walks into my clinic, the first thing I do is sit down once they're comfortable, ask how they are, and then as I'm asking how they are, I put my hands on their wrists and feel for their pulse. And I think what I was so taken by at that time was the rhythm and how much you could get out of that, of touching someone there, feeling their pulse, feeling the rhythm of their life, literally, and the nature and the quality of that pulse. And from that experience on, I knew I wanted to be a doctor and I also knew I wanted to do cardiology.
What do you feel for when you feel a patient's pulse?
Dr. Anu Lala: 07:04
The first part of it is just touching the patient, skin to skin.
What does that do?
Dr. Anu Lala: 07:08
I think it almost enables a sort of immediate connection. It almost breaks barriers. And I know it's challenging to talk about skin-to-skin connection in COVID times, but it just—whatever walls are up, it kind of brings them down immediately. And so I sit in front of the patient, I put my fingers on both of their wrists and I look at them in their eyes and then ask them about—it could be superficial conversation, but it's a connection that's established. And then what I'm feeling for is the nature of that pulse, the strength of it, whether it's bounding or whether it's weak, whether it's slow or whether it's fast, whether it's thready or whether it's coming up against my fingertips. It's hard to articulate, but I've now developed a sense of understanding the circulation and also their state of mind, their physiological state at that time.
We talked a little bit about the heart as myth and metaphor, but it's also an incredible physical organ. Tell us about that.
Dr. Anu Lala: 08:29
What I love about the heart is how many functions it performs. So it's not only a pump responsible for literally pumping blood to the rest of the body, but it also has an electrical system that governs how it pumps and provides the rhythm for the body. It's literally your body's pacemaker. I love that there's physics involved and fluid mechanics involved and valves opening and closing. And this almost sounds silly, but I love how the color of the blood changes from one chamber to the next, so you have deoxygenated or blue blood coming to the heart seeking restoration, if you will, with oxygen and nutrients, and so the heart pumps that blood to the lungs only to be within a microsecond receiving blood from the lungs that's now bright red and full of oxygen and nutrients. And then it sends it out to the rest of the body. And I think it's such a beautiful representation of being energy-depleted and then being energy-repleted all in one beat. And so I just love how multifaceted the heart is.
I'm stuck on that image of the blue blood coming in and the bright red blood going out. It's like—listeners can't see this, but there are Buddhas and there are Hindu images and there are all sorts of spiritual images in here. And there's also a heart, and the heart fits right in given what we're talking about and given the heart's function as a restorative organ. How would you describe your philosophy of the doctor-patient relationship? Because I know that's very important to you.
Dr. Anu Lala: 10:19
So the first thing is really being able to establish that human connection. Like I said, shutting the barriers and the layers and just connecting human to human, recognizing that this is a human experience, confronting disease and illness is a human experience. And so I think that's really important to me. And I'm not going to lie, I mean, there are times where you get caught up in the roles that we play—I'm a physician, you’re a patient—but the most satisfying and fulfilling encounters are the ones where we shed those roles and recognize the humanness of our connection. And then it's about empowering patients and their families to accept what is, which is the hardest part. Anyone who's told that their heart is not functioning, or that they need a new heart—it's devastating news. And the human inclination is to resist it or not want to accept it or feel self-pity or feel unlucky. All of these things are completely normal. And if I could do one thing, it's my prayer and hope that I can help patients accept what is. And that requires giving them information in a way that's not debilitating. So that's the first part of it. And then once we accept—
Wait, what does that mean? What does it mean to give a patient information in a way that's not debilitating. How do you do that?
Dr. Anu Lala: 12:02
I don't know [laughs]. I think when you align yourself with what is, then there's room for acceptance to flow in. And when you accept what is, then you recognize the opportunities in that given situation. So I know I'm being vague, but I'm obviously a heart transplant physician and a heart function doctor, so I have young patients. I have a young patient who just celebrated Father's Day four months out from his heart transplant with his two little boys. And he was told at the age of 38 that his heart was not functioning and that he would need a new heart. And he stayed in hospital for three months waiting for that new heart. And then once he had the surgery, he had challenges and bumps along the road. Before he could go home it was another several weeks. And so each day was about providing information in an objective way and then moving towards acceptance. And so when I say that I provide information or I try to provide information in a non-debilitating way, I like to try and focus on what is working rather than what is not working.
What do you say?
Dr. Anu Lala: 13:23
So with this particular patient who I became very close with, we would start the day off with, let's talk about all the things that are working. So your brain is working. We're having this conversation right now. You can see, you can hear, you can taste, you can smell. Your lungs are working, you're not on oxygen. Your kidneys are working. You're making a lot of urine in response to the medicine that we're giving you.
Really going down the list!
Dr. Anu Lala: 13:48
Oh, yeah! Your limbs are working. You're able to write and communicate with your family. You're able to walk, your bowels are moving. Your liver is working. And then, yeah, your heart is not functioning well, and that's why we need to replace it. But when you contextualize it like that, I'm not sugar-coating anything by any means, but I am hopefully allowing for recognition of all the things that are working. And I think that's true of life. When you only focus on what's not working out in your life, then you feel like, oh, woe is me. Why me? Pity party sort of situation. But when you try and shift your attention to what is working and have gratitude for what is working, I think it allows for more acceptance for the challenge that you're faced with.
Yeah, it strikes me that anybody could get up first thing in the morning and go through their bodily systems and say, well, this is working, this is working, this is working. Maybe not a bad idea.
Dr. Anu Lala: 14:50
It's an amazing idea. I wish I could do it more often. It's easier to say these things when you're confronted with someone else seeking your guidance. But I think if we could do that, I mean, some of the most effective meditation practices are exactly that, right? Focusing on the breath, the fact that you're able to breathe is pretty amazing.
Language is important to you. Not saying "heart failure." Why is that?
Dr. Anu Lala: 15:17
Yeah, thank you so much for bringing that up. That's something I feel so passionately about. The word "heart failure" or the term "heart failure" is just—I talk a lot about empowerment and not wanting to give patients information in a way that's debilitating. That's a perfect example. By opening up and telling patients, particularly young ones, "You have heart failure." I can't imagine a more devastating diagnosis. Because the word "failure" is perhaps the most negative word in the English language. And so I think we do patients a disservice by using that term. So I and others in the community are really, really trying hard to change the language we use to focus on function rather than—I honestly can't even say it [laughs], "failure," because that implies the end of the road. It implies that there's not a lot of options left. It implies that it's time to be hopeless, quite frankly. And I think when we talk about function, we can talk about the entire timeline. We can talk about prevention. We can talk about maintenance of health, preservation of function, restoration of function, and replacement of function if and when necessary. But I think it just opens up how we can speak about the patient's particular problem. And I can tell you, I had another patient, also a young father, a successful entrepreneur, had everything going for him, and was told that he had heart failure. And he said, "Just don't tell me that. I don't want to hear it. I can't accept that." He goes, "I don't fail at things in life." And that really struck me.
Well, what came to mind for me is that “failure” is also a moral term. You talk about the failure of a body, the failure of a heart. It's kind of like, "Oh. What did I do wrong?"
Dr. Anu Lala: 17:20
Right. What did I do wrong? Or why me? And so I immediately connected with this other patient about function. And he was like, "Yeah, that really sits with me. Let's do that." I also like the word "function" because it's not just the heart. It's how you function as a human being as well. And they go hand in hand.
That seems to get to something else I want to ask you, which is about the "why." That heart function has to do also with the functioning of the person with their heart and what they want to do.
Dr. Anu Lala: 17:50
That's right. That's so right. When I am trying to present options for therapy or next steps to a patient, for me it's really, really important to understand what their "why" is. What's their motivation? And that might sound very trite and almost silly, you know, what's your motivation to live? Some patients are like, "What do you mean? Of course I want to live!" And so obviously you ask it in a more finessed and sensitive way. And so it's more so, well, what do you enjoy doing? What's an ideal day for you?
It's almost like, what's your heart for?
Dr. Anu Lala: 18:24
Yeah. Right. What makes you tick so to speak? I had a patient recently who I met in the CCU who did not want to hear about a machine to take over for her heart.
Dr. Anu Lala: 18:39
I'm sorry, the cardiac care unit. And she didn't want to hear about a machine to take over the function of her heart, called an LVAD. She said, "Oh, absolutely not. That's not for me." And I said, "What's an ideal day for you?" She said, "Well, taking my grandson to the park." I said, "Well, how do you take him to the park? You can barely walk. You know, your heart is weak, and you feel so short of breath and tired." And she says, "Yeah, we go slowly. He holds my hand. And he tells me about his day at school. And then I sit on the park bench and he plays on the playground, but he keeps checking in with me. And then we slowly walk home. And to me, that's the ideal time. I don't think about any problems during that time. I feel like life is full." And that was so telling to me. And I said, "It sounds like you would like to keep doing that." And I said to her, "Well, what if I told you that having an LVAD, having this machine to take over your heart, would allow you to keep doing that. And maybe even more." And with that a window opened where there was a wall in terms of hearing about this option and what the machine was like. And then there was, "Well, tell me a little bit more about this machine. What would it be like? What does it involve?" And so that's just an example of when you get to the patient's "why," you can help offer ways to continue. And that's not always the case. It's not. And there's tremendous dignity in allowing a patient to transition to end of life as well. But first understanding the "why," I think, is critical.
We talked a little bit about uncertainty. You deal with a lot of patients who are in a very uncertain situation, who don't know what today or what tomorrow is going to bring. How do you guide them?
Dr. Anu Lala: 20:41
I wish we all had guidance on that. I think uncertainty is the most—at least for me, honestly, that's a big challenge that I face in my everyday life. When you have children, you have loved ones, career things, and you wonder what's going to happen. You want to know the outcome of a journey before it starts. But it's particularly relevant, as you bring up, in cases of disease or illness. I'm faced with it all the time. All the time. I just had another patient who said, "Well, is this definitely going to happen tomorrow? Am I definitely going to get a heart? Am I definitely going to have it within three months? Am I definitely going to survive for 10 years after I get a new heart?" And all of these questions, I always say, "I don't know for sure. Nothing is certain. But what I can tell you are statistics. I can share with you what we've learned over the years. But what we do have is this moment right now, and what I know right now." And the more that we shift our focus to the present moment, the more we're aligned, as you mentioned, with the present moment, the more there's acceptance. And the biggest word that I use and that I think is so profoundly powerful is "surrender." I always say this. I mean, any one of my patients that you speak to will tell you I say, "All we can do is surrender." What we can do is provide you with the knowledge, with the information. We can, thank god, here at Sinai we have the ability to provide every possible therapeutic option. But we don't ultimately have full control over the result of what happens, and that's the case with anything in life. And so when you surrender to the present moment, you accept what it is for what it is. I think there's empowerment in that. And there is peace in that. And if I can help a patient see that and even remind myself of that, then I think that's beautiful.
Do you ever get emotional with your patients?
Dr. Anu Lala: 23:03
Oh gosh, yeah. Sometimes yes. Sometimes no. Sometimes I surprise myself with how not, you know, tearful I'll be in a given situation. And then there are other times where it happens out of nowhere. We had a patient now over a year and a half ago who was young and had a heart transplant when he was a child and then was confronted with needing another heart transplant at the age of 23. And there were a lot of ethical discussions about this, and he had a particularly challenging situation from a physiologic standpoint. And what was amazing for me as a learning experience is we got to work with the pediatric side of things and see how—. They were so involved in taking care of him for all these years, and even though he was officially on the adult side, in many ways he had spent a lot of his childhood in the hospital. And so we worked with his pediatrician, we worked with an art therapist, and what struck me and what changed me was how they spoke to their patients. Because they constantly asked this particular patient if he would be okay with talking about next steps. And so what I witnessed with them was that they were always empowering. They were always putting the ball in the patient's court. I can just remember everything about this particular encounter where the therapist said, "You remember when I told you that we might get to a point where we really need to talk about next steps and that we might be running out of options?" And I remember him saying, "Yes." And then she said, "I think we're at that point now." And he just kind of stayed quiet. And she said, "Do you want to hear about what those next steps might look like?" And to me, in the moment, it was like what do you mean? We have to tell him what the next steps will look like.
Oh, I see the difference.
Dr. Anu Lala: 25:12
So what if he says, "No"? We can't just walk out of the room. But it was about empowering him to guide next steps. And I thought it was so beautifully done. And I think we can learn so much from how the pediatric folks do that. And so I've sort of incorporated that into my conversations with patients as well.
You do a lot of listening.
Dr. Anu Lala: 25:34
I think we try to, yeah.
You mentioned to me in a previous conversation that you will listen to patients who've died and come back to life, if you will. Can you share anything that you've heard that has stuck with you?
Dr. Anu Lala: 25:47
Yeah, I mean, to some people it will sound almost voodoo-esque, but what I have come to say and believe is anything is possible. And so I remain open to what patients want to share. I judge less and less and less, and that's my prayer for me as a physician, as a healer, as a person, is to be void of judgment. Because they've seen things that I haven't. They've experienced things that I haven't. And so I've had many patients who have quote-unquote "died and come back to life"—cardiac arrest, their heart stops for several seconds, minutes, sometimes longer, and then they're here alive to tell the story. And I've heard a variety of stories. One woman in particular comes to mind who's a psychologist and a therapist, who, while she was waiting for her heart, was actually continuing therapy for her clients, if you can imagine, while she was in the hospital. And she had a very difficult experience where her heart stopped. And I spoke to her the next day and she was actually well and fine, remarkably, and she became emotional. And she said, "You know, I literally remember waking up screaming, saying, 'No, I'm not ready to go. It's not my time.'" And she goes, "And I think because I said it so forcefully and it came from such a deep place I think I'm here today to talk to you about it." And I told her, I said, "I believe you." I believe it because we hear all kinds of stories like that all the time. So, you know, I think if anything this just makes us so humble. There's so much we don't know. We think we know so much, right, especially doctors. We go to medical school then we do residency then we do fellowship and—
Anu, we're surrounded by your diplomas, literally, on three walls. To your point.
Dr. Anu Lala: 27:57
Right and so you get to this point where you think you know it. And I think this field in particular teaches us that there is just so much we don't know both physiologically, but also spiritually. I think initially when I started out, I would be afraid to tell patients and families I didn't know the answer. And now I find so much power in that. When they ask certain questions, I say, "I don't know. But we can figure it out together, or we can try and find answers to that." Because I think that lends so much more credence to what I do know. And I've found, surprisingly or not surprisingly, that it allows for more trust because they know when I say I know something, I actually, at least I think I know it. Whereas when I say I don't, I'm being honest and upfront with the fact that I don't. And I think it's really important to relay that to patients and families.
Very unfortunately I want to bring it down to a more practical plane by asking you what are some things that you do to cope with the stress of your work?
Dr. Anu Lala: 29:13
One thing that came to me that I think is actually so cool and so profound is that if you look at the heart as an organ, it's responsible for pumping blood and oxygen and nutrients to the rest of the body and to perfuse organs, your brain, all your organs, your kidney, your gut, et cetera. But it needs its own nutrients. It needs its own source of energy. And for that it has these arteries or these vessels that are reserved for itself, to provide nutrients, blood oxygen to itself so it can continue providing for the rest of the body. And if you think about it, what is a heart attack? A heart attack is when one of those arteries called the coronary artery is blocked. And so the heart muscle doesn't get perfusion or oxygen or blood or nutrients, however you want to look at it, because there's an obstruction or a blockage. And so part of that muscle function then dies. And I think for us as providers or clinicians or physicians, it's kind of the same thing. You have to take care of yourself while you take care of others. And in fact, unless you do that, you're not going to be able to provide for others or serve others in any meaningful capacity. What I hope we will see with time is a greater emphasis on that. More and more now we talk about physician wellness and wellbeing, but it's not just hip and cool to talk about, it's real. And that analogy to me is actually so profound and it's kind of the same thing. So I have realized that I need maintenance, I need restoration. And so for me it's about—any kind of workout generally does it, whether it's running or yoga, or even just a high-intensity Orangetheory workout. Anything that really gets me going in terms of getting my heart rate up is really, really helpful for me. I think spending time in meditation is helpful and writing, writing in my journal is helpful. I think there's a distinction between doing things that you love and enjoy— nothing is better for me than spending time with my children and my husband and my family—but you have to recognize that while that's amazing, it may not necessarily be nurturing to you. And there's a distinction. And I'm slowly starting to realize that and trying to devote designated time to nurture myself.
You have a copy of the Bhagavad Gita in front of you, the sacred text. Was there something that you wanted to share from it?
Dr. Anu Lala: 32:23
|No other than, you know, we have all of these texts, these spiritual books, and we're all ultimately seeking joy and peace. Ultimately that's what we want. We want to feel heard and seen. And we want to feel peaceful, tranquil and joyous inside. I think that's a pretty much universal human desire. And what strikes me is no matter what texts you read or what podcasts you listen to, it's all about really aligning yourself with the present moment and recognizing the beauty of what is. Like, I'm here with you now—it makes me want to cry because it's amazing. We're connecting on a different level and we're in good health and we're enjoying a beautiful conversation. And so this moment is perfect as it is. It's whole and complete. And I say this thing to my children before they sleep, there's a Sanskrit shloka or mantra, if you will, that says, it basically is purnamadah, and everything is about wholeness. And so what we say after that is, "All is perfect, whole and complete. You are perfect, whole and complete. I am perfect, whole and complete. And this moment is perfect, whole and complete."
Thank you so much, Dr. Lala, for taking this time.
Dr. Anu Lala: 34:01
Thank you so much.
Dr. Anu Lala is a heart function cardiologist here at Mount Sinai. Thank you again, Dr. Lala, for that conversation. Road to Resilience is a production of the Mount Sinai Health System in New York City. It's made by me, Nicci Cheatham, and our warmhearted executive producer, Lucia Lee. From all of us here, thank you so much for listening, and we'll see you next time.