Shiv Gaglani: Hi, I’m Shiv Gaglani, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

I recently attended Grand Rounds at Johns Hopkins featuring today's guest, Dr. Susan Mackinnon, and knew immediately I wanted her to be a guest on Raise the Line because she has such important messages to share. Given her pioneering work in peripheral nerve transfer and regeneration, as well as leadership of national medical societies, you'd expect the focus of today's show to be on her many professional accomplishments -- and while we'll be touching on some of that -- her passion and research is now focused on changing the culture and climate in the medical profession with an emphasis on finding happiness at work, spurring innovation, and the importance of self-care for providers.

Dr. Mackinnon is a professor of plastic and reconstructive surgery and the director of the Center for Nerve Injury and Paralysis at Washington University School of Medicine in St. Louis. 

So, Dr. Mackinnon, thanks for taking the time to be with us today.

Dr. Susan Mackinnon: Well, thanks very much Shiv and please call me Susan.

Shiv: Okay, Susan. Well, I'd like to start where we always start with our guests, which is, can you tell us a bit more about your journey into the field of healthcare, and then specifically into surgery? 

Dr. Mackinnon: My journey into healthcare and surgery was terrific. So, it started with a fabulous teacher, Lew Bobb, who came from New Zealand. It was high school, and he taught history. He was such a great charismatic person, and so wise and so engaged, that I wanted to be a historian. And I’m thinking, “Now, I don't know if I want to be an historian, but I wanted to be like Lew Bobb.”

He was a Māori Indian and went to London and then Oxford and then landed in Toronto. Oh, such a great guy. So, I told him I was going to do history and he said, “Oh, why do you want to do that?” And I said, “Well, because it's so repetitive, and if you just let people know what was going on, all this ego, fighting over this and that…then we would get rid of all the wars and the world would be wonderful.” And he said, “You're very naïve. You won't change anything. Do something practical.” And then my practical was going to medicine where it will always be a good job and then I can help people. How great was that? 

So, it was 1969 when I got into pre-med, and it was rugged. There were eight women, and the rest were all men at Queen's University, a top school in Canada. I had a struggle getting in, apparently. The dean was named Edmund Botterell, he was a neurosurgeon and had led the neurosurgical fights in the Second World War. I found a letter just last year in my father’s papers about how Dean Botterell had said no, she can't go into pre-med, even though she stood top in her class and was twenty points above some of the men, because she should just go into like, other issues and, and have a happy life or something. 

So, when I did get into pre-med, I was nineteen-years-old. In the summer of that year, I was sitting in a small room on campus at a job at the university doing something in a lab, and I went to this lecture and the same guy, Dean Botterell, was at the end of a table about ten of us. I remember exactly where I was sitting. He was over there. I was here. There was a window looking out at the lake in Kingston. He talked about the effect of norepinephrine on spinal cord injuries and I was just fascinated. So, he was a big part in my journey in nerve. 

And then through medical school, I did every single nerve rotation I could do -- neuroanatomy, pathology, neuroradiology, neuro everything -- and I knew I was going to be a neurologist. I stood first in my class over the four years -- never first in any year, but accumulated over the four years  I was first in my class -- and I had matched into an internship in medicine, and was planning to do neurology, but I just had my first child, Lachlan, on June the eighteenth and I wanted to have my week vacation at the beginning of August. We have a camp up in Northern Ontario, still have it, and I wanted to take Lachlan up to meet my family up there. 

I made an appointment -- how bold was I -- with the dean of Medicine, Larry Wilson, and I said, “I'm entitled to this time off and I'd like to take it in August, because that's the only time that ice is off the lake.” Literally ice is off in June and it starts to snow in August. He said to me, again, “You know, maybe you shouldn't even be in medicine. I understand your priorities but you know, the patient is first here.” I remember exactly where he was sitting, where I was sitting. I still don't know how I actually got a meeting with the dean, and I thought, “I don't want to work for you for five or six years.” I had got the professor's prize in surgery and a friend of mine decided he didn't want to be an intern in surgery because he wanted to be an ophthalmologist, so we switched and then I went into surgery and then I had a similar path. 

Oh I've had the same experience all my life…these weird things happening. A big problem then it's not a problem and it's a good problem to have because then it moves me somewhere else. Is that good enough? 

Shiv: Yeah, I love that. There's a couple of takeaways from that. One example is how your interactions and attitudes with someone can change over time. Like, for example, the first dean, the neurosurgeon you mentioned, was not supportive but then a lecture he or the team gave wound up becoming a good moment for you that set the stage of your life.

Dr. Mackinnon: Yeah. 

Shiv: We're big fans of stoicism here at the podcast and a lot of the things we share are about how you encounter challenges in your career and then become grateful for those challenges because they set you on a new path, or the process of overcoming that challenge helps you succeed even more beyond what you thought, which is clearly the case with you. 

So, once you became a surgeon you were still interested in nerve. Can you set the stage for what your pioneering work in nerve allograft has been, because I think that's one of the things our audience loves to hear about, how did people who are so impressive like yourself make your discovery or do that first successful allograft? 

Dr. Mackinnon: Well, I was in plastic surgery at the University of Toronto and I actually wasn't that interested in plastic surgery but I was offered a job in that. My husband was offered a job in vascular surgery. We both needed a job, so off we went. I  was going to do microsurgery at Queen's University and I wanted to work with a guy named Ralph Manktelow who'd done the first procedure taking a muscle from the leg and putting it in the forearm transfer in North America to get back hand function. So, I manipulated as much as I could so I could be there in January of 1978 or something do a six-month rotation with him at St. Michael's Hospital. 

There are six big university hospitals at the University of Toronto. I worked so hard to get that rotation. I was so excited. I arrived there at the end of December and on January 1st, they moved him to the Toronto General Hospital and he wasn't there and I was so disappointed. But there was a guy named Alan Hudson who was chairman of neurosurgery and he had trained in South Africa. He was a marvelous surgeon and he was one of the two people in North America that owned the area of nerve surgery. He really took me under his wing because I was down there at St. Mike's with all this free time. This guy that was there at his private practice in the afternoon didn't want anybody like me hanging around with the facelift surgeries, so I hung out in Alan’s lab and in his operating rooms and his clinic and he became a major mentor for me. 

I will say that the reason I came to Toronto was he decided that we were going to start a nerve center together. This is now 1991, and he brought me down to the Toronto General and we were getting going on it and then he came in February or January and said, “I don't think I’m going to do clinical stuff anymore. I’m going to be president of the hospital.” In March, my husband Alec and I were in a ski line, at Whistler and we decided we're going to leave. Alan got wind that we were leaving, actually, and in August of that same year we were in St. Louis. So, bang!

But in the meantime -- talking about mentors good and bad or whatever -- he was my mentor and he still is my mentor. He sent me a copy of his beautiful book about his whole life but he forgot the part about how he didn't want me to go and he sued me for half a million dollars for trying to go to St. Louis and he had this whole full scap and he had this person come and drop it on my desk and I had to get a lawyer so he wouldn't. So, you know, where do I have five hundred thousand dollars when I’m forty-years-old? But now we're reorganized again.  

So, he gave me the idea for nerve allotransplantation. Here's what good mentors do, they give away ideas because they are seasoned and they know what the big picture is and they give you the idea and they don't hoard it back again. It's not like giving it and taking it. But the idea was nerve allotransplantation; no surprise because in the beginning of the 1980s you had cyclosporine and then fk506 was available, but just experimental, and that's when people started doing the transplants of the kidneys and the livers and the lungs. Like, my husband scrubbed in on the first single lung transplant and he did research work for two years in the lab to facilitate the double lung because for diseases like cystic and pulmonary fibrosis, it's a bilateral lung problem and if you do a single then you'll just infect the  donor. So he did the work on how to keep the trachea alive and he did the first double lung in Toronto. 

So, that is part of it too. I could do the nerve allotransplantation based on adapting all of the stuff that they did in the lab on lung transplant into nerve. And we did the first nerve allotransplant and several of them. But at the same time I had this lab and as we were working in the lab on all of this, we started to see that, oh my gosh, as the nerves got longer they started to fail. Ugh. It was depressing. Then we were going to do longer and longer allos, we were going to take the whole plexus out, and vascularize. It was just going to be fantastic and then we realized, “Well, what's the point because when you expand the length you get failure. 

But then that failure led to nerve transfers where you'd have an injury up in the brachial plexus, for example, and what we were doing was harvesting both surals to put in these long grafts to reconstruct the plexus and then wanting to do allografts. Then in the lab we were seeing well, things are starting to dwindle. You're getting Schwann cells that were becoming senescent and they were producing a situation where it would just stop regeneration. So, that failure was the impetus for something better and that something better was nerve transfers and that came from working with Alan Hudson who was this guru in nerve graft but at the same time working with Jim Murray in Toronto where he was taught by Bill Littler from New York who was taught by Sterling Bunnell who started hand surgery. 

So, as the fourth generation of that…that was all tendon transfers and Alan Hudson was nerve graft so why wouldn't Susan Mackinnon take the nerve from the nerve graft and the transfer from the tendon and just go proximal a bit and instead of taking the tendon over, come up and find the nerve and move the nerve over. And that was, and remains, absolutely out of the ballpark successful. 

Shiv: That's awesome. That's a great story and I love the themes you've touched upon of creativity and how you get ideas from here and there and the timing is right with immunosuppression coming to the field in the 80s. It’s very interesting. Two other surgeons I was able to work with at Hopkins directly or interact with directly are Dr. John Cameron, who helped perfect the Whipple procedure for pancreatic cancer -- you know Andrew Cameron, his son, who introduced you -- and Dr. Patrick Walsh who helped figure out how to do the modern radical prostatectomy with sparing the neurovascular bundle. I had the chance to be in clinic with Dr. Walsh and learn he was eighty-six. He's sharp as a tack. I’m very impressed with people who've had incredible decades worth of contributions like yourself.

Dr. Mackinnon:  He's in clinic at eighty-six?  

Shiv:  He's not doing surgery anymore, but I saw four patients with him last week. He'll be wrapping that up but still doing research. 

Dr. Mackinnon: As I got older, I realized that cultures and climates that are really special treat the young and the old very well.

Shiv: Yes.  

Dr. Mackinnon: So, that's a good story to hear that. 

Shiv:  Oh, it's wonderful. You know, I've benefited personally from a lot of people in their eighties who've mentored and have been doing research on the health and wellness of patients. 

One quick story I think you'll appreciate is about Dr. Catherine DeAngelis who was the first female editor-in-chief of JAMA and she's at Hopkins. A decade ago, I asked her for some advice as I was leaving school to create Osmosis. She was in her mid-to-late 70s at the time, so I asked her if she was retired. And she said, “Shiv, honey, I never tired the first time. How can I retire?” And I think that's a theme for some people.

Dr. Mackinnon: That's lovely. I'll take that.

Shiv: Yeah, you should. 

Dr. Mackinnon: I was never tired the first time. Why should I retire? Oh, that's beautiful. 

Shiv: Well, I want to ask you about yourself. So, obviously, you have the right combination of mentorship, hard work and skill, and probably some ambition. I would love to hear, like, what does it take, in your opinion, to do something as pioneering as you've done? Like, if someone's listening to this and wants to make a mark in the field? 

Dr. Mackinnon: Oh, that's a yummy, yummy question. Fantastic question. I have the answer.

And how I have the answer is, I studied it. But, oh boy… doing something new. If you're doing something new, even for the people on this listening, if you're at the podium presenting something and you don't get any questions, it's almost always because this is new and people are thinking about it. If you talk about something simple, like gallbladders or carpal tunnel or something, everybody's running to the microphone because everybody's got an opinion. But when you're doing something new, woo! 

And then if it is really new, you are definitely ruffling the feathers of the people in the old paradigm. I didn't know about paradigm shifts until I was in the middle of it -- going from nerve graft to nerve transfer. There's a book by Thomas Kuhn on the scientific revolution, and he quotes Max Planck who (I’m paraphrasing) said, “No one from the old paradigm is going to buy in. Just don't even go there. They just have to die off and new people have to be born into that paradigm.” It's a revolution, it's a crisis, and it's chaos.

When I was going around introducing nerve transfers that came to me because of that story and then having this lab where I could test everything. But it hit people like a sucker punch, and they were angry. Of course, powerful women and black males can be perceived as scary in our culture and so there was a lot of pushback. It wasn't very nice. I reached out to Hanno Millesi, who had been the first to push the paradigm in nerve grafting from nerve repair. He gave me some wise advice and told mehow rugged it was then, but I studied it. 

I studied myself and I studied the situation I had myself in. So, I know the answer because I studied it. If anybody has a pencil and paper, I want to note several books and thinkers that influenced me. One is The Structure of Scientific Revolutions by Thomas Kuhn so you know what you're up against. I didn't even know I was doing nerve transfers until one of my residents said to me in the early 90s, “You know, Dr. Mackinnon, you don't do many grafts anymore. You're doing all these transfers.” I didn't even name it. 

And then, of course, there’s Anders Ericsson, who went by Karl, who introduced the idea that there were outliers in performance and ideas about how you need a coach, work hard, and you have deliberate practice. And then Steve Johnson, who wrote Where Good Ideas Come From. So, I'll pause on that because when I read that, I had to give a talk on this shifting at ASRM, that's the micro society. I remember opening up Time Magazine like three weeks before I gave the talk and they're talking about Steve Johnson's book, which is basically fantastic. It gives me all this information. So, all these things came to me. Like, Kuhn's book was given to me by a friend of mine, and Anders Ericsson…I bumped into him at a meeting that my husband was running in North Carolina and he was there as the speaker. At the same time, there was an article about Karl in Time Magazine and there was this write-up about Steve Johnson. 

So, there are six things that I've pulled out of Where Good Ideas Come From. One isadjacent possibility. You can have an idea that's a great idea -- there were drawings of nerve transfers in the textbooks in 1911 -- but an idea before it's time, because the adjacent possibility of microsurgery and instrumentations and magnification wasn't there. We weren't even allowed to touch the nerve then, let alone go inside. That's one of the things that I did, I went inside. No one had ever been there, and when I got in there and I could stimulate in the middle of these fascicles…if you stimulate the radial nerve up at the shoulder, you can pull out thumb extension. It's just like, Wow. Wow. Going inside a nerve, you couldn't do that in 1911. It was an idea before its time. So, adjacent possibility, and then also Johnson talks about pushing to the boundaries. 

The next thing is having a group of people, like a level six -- when I talk about Bruce Schneider's seven levels, level six is connection -- it is happiness and joy. It's oxytocin. It's seeing yourself in everybody. We're all the same. It's everybody's head at the table, and that's when innovation happens. That's when you are your wisest self. He talks about that. 

The word serendipity comes from the Princes of Serendip. There are three of them and everything they touch turned perfect all the time. So you need that serendipity. And then he says it's slow and that's another message for the audience. It's slow. You're talking to someone who's been doing this for four-zero years. It's slow. And the other biggie that I talked about is lots of failure. So, accept failure immediately. It took me a while to learn that. I remember one of my guys working with me said, “Are you ever going to give up that idea about the allograft? It made such sense, but I gotta give it up. You're right. It doesn't work. Okay. So, accept failure immediately. Don't resist it. What you resist persists.

Then, um…I can't remember what the last book is. I love that Steve Johnson so much. Oh, I know! Sure. It's David Logan's book Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization.

Shiv: Oh yeah. 

Dr. Mackinnon: And tribes are basically the same thing as Bruce Schneider's seven levels. It's self, ego, needy, human doing human, and then being a human, and then the level of being a human, where you're connecting with other people. And then you move past that into the biggest connection where these ideas are just given to you, just a gift, because it's coming from the knowledge that is the creator's knowledge and all of a sudden it just lands in front of you. 

Shiv: Oh, my goodness. I love that. You're speaking my love language of books. I've only read two of those books you mentioned. So, I’ve got to go back and look at it, but thanks. You know, who needs Blinkist!

Dr. Mackinnon: You know, another great book to write down is Rick Rubin's book. 

Shiv: Oh, on creativity.

Dr. Mackinnon: Yeah. On creativity and being.

Shiv: Awesome. I haven't read it, but I've heard him on a podcast. 

Dr. Mackinnon: It's terrific. I’m doing my second edition of my book Nerve Surgery, and I have to do a preface. And the moment I have to do the preface, I watch Anderson Cooper on 60 Minutes and he is interviewing Rick Rubin and the next day, on Monday, I’m in the airport going to see the Vermeers in Amsterdam with my husband for our fifty-first wedding anniversary and there is his book. All the way over I’m reading his book, and basically his book is my preface -- it is how to be me -- is to live at these high levels of energy and not get sucked into the low levels of survivor brain where it's all about your ego. I win. You lose. Nothing happens there, but having been there for two years or rather put there for two years that's how I came to talk to you about culture and climate. And that's what I talked about at Hopkins. This is not my quote, this is someone from Duke, who said that, “Surgery is only separated from a cocaine addict by five generations.” Yeah, I'm in those mighty halls to talk about culture. 

Shiv: Yeah, that's hilarious. So, let’s turn to culture. You said this on the Grand Rounds, and I wish we had that recorded to be able to share with our audience to…

Dr. Mackinnon: I’m going to record it. I gave that as the Olga Johansson lecture by the American College of Surgeons and they have it recorded. So, that could be something if they let it outside of the ACS. But really I love talking to you because I want everybody to know the tricks of Bruce Schneider and his seven levels. He's taken the philosophy and all the great religions and all the wise thinkers from soup to nuts -- from Buddha to Jesus Christ, Mohammed, just everything -- and brought it into an easy for surgeons or medicine people or anyone to be able to have an awareness instantly in the moment, every moment, of whether they're being a needy human where nothing happens -- except you basically kick up the adrenaline and cortisol, and you're going to twist off your telomeres and get old earlier, just stress yourself out with all these inflammatory things going on where we're looking after our patients and our families -- to the human being at levels six and seven. That’s where all of the neurotransmitters like the oxytocin and the anandamide -- which is the neurotransmitter for bliss, which is like, flow seven -- and that comes from the Sanskrit word Ananda, which is bliss. So yeah, I want to teach that and I want everybody to have that. 

Shiv: I’m going to ask you a bit more about it, too, but what got you interested? So obviously, you're pioneering nerve surgeries and nerve transfers. What is your hero's arc to getting into changing the culture of medicine through the things that are in the talk at Grand Rounds? Talk to us about kind of the breakdown moment, if there was one, and then the rebuild from there?

Dr. Mackinnon: Oh, for sure. So, Colin West at Mayo Clinic wrote a white paper on what we should be doing for wellness. In it, he says leaders should be vulnerable and practice self-compassion. So, if I believe in that, and I do believe in that for wellness, I will tell you this story. I was interested, you know, about how they treat old people at Hopkins versus how they treat the elders at the institution I’m at. I don't think it was just because I was powerful, but I think they had other plans for me, and so the leadership was harsh. I don't think it was necessarily anything personal, but they just sort of had different plans for me. And I think really the next part of my life story was “enter stage left, and rough the heroine up, and burn her out, and then we'll carry on.” So it really was that. 

Then there's a short intermission for two years where I got out of level one and two, this sort of separated self, this going on, this survival. Interestingly, it was during COVID as well. I remember thinking like, holy mackerel, Lord, I am not strong enough for this. But I studied it. I studied what it was like to be in those low levels where I had never been except, you know, when I wanted to…when I was marching for abortion rights in Canada as a teenager, and then my pink hat later on and this kind of stuff, like, I would be at the level one or level two which is “I win, you lose.” That's all that negative adrenaline and cortisol and I was there for at least two years, three years, something like that. 

I studied myself and I studied this whole situation. I was given by the institution these two great guys that coached me. They said, you have to give leadership in the hierarchy -- not all hierarchies in all schools are like this -- but give them what they value, and they value power and control. The third part is subservience. So, give away my power and give away my control and be a servant. Like, I didn't really buy into that. But serendipity stepped in. A friend of mine who I made some yoga videos for her, she was opening up all the COVID cardiac anesthesiologists at WashU, she was opening up these COVID units, and we sort of buddied up. I was teaching meditation and some little things… yoga by the bedside because all of her people were burning out. And she had researched iPEC, Institute of Professional Excellence in Coaching. I thought forever as I was studying it, that it was the Institute of Positive Energy Coaching. 

Bruce Schneider started it. There's like 10,000 people that have been trained by him, or more, around the world. I've never met him. I'd love to meet him, because he has studied everything. You know, all the other people like Eckhart Tolle, and Jon Kabat-Zinn, and Tara Brach, and Pema Chodron, and all the other people. He studied them, and he just put this in this very logical manner of basically, what we know about stimulus response. 

So, a thought drives a response. The default comes from what's going on in your culture when you're brought up, and then how your caretakers, your parents, whoever -- who may even love you -- but kind of give you these thoughts that just aren't helpful. For most all of us the thought is, “I'm not good enough. Am I good enough yet?” That is you level two-ing yourself, like, you don't win, you're not good enough. Everybody has that. And then moving up, level three is deep breath, accepting. Level four is compassion for our patients. Five is win-win, no failure. I teach at five. If you do pimping, it's level two. I know something you don't know. Now, there's no performance at one and two, but as you go up, the performance increases, and the neurotransmitters increase.

So it’s the sympathetic nervous system -- fight, flight, freeze -- versus the parasympathetic -- rest and relaxation -- where you're really able to do anything you want. And then practice and practice and practice and still practice how to immediately be aware when things aren't right. Accept it immediately. Dig in a little bit as to what nasty feeling you're feeling. Take a breath, comfort yourself, comfort everybody else. Give yourself some, like, I’m now holding my arms. You don't have to do like shoulder to shoulder where people think you're an idiot, but you can just hold your elbows. And that is just comforting. Level four yourself, compassion for patients, compassion for you. And then you're right. The next one up, peace and calm, serotonin, ideas everywhere, opportunities everywhere, no failure. And right above that is oxytocin and happiness and joy where you create. 

So, I got into it because my whole life was that high level and I rarely was at one and two until I was at one and two for a few years. Apparently I needed to be there. This whole thing didn't just happen to me. It happened for me and I am so grateful for that. I would not be talking to you without that. Now I know also this practice of loving kindness, self-compassion. It also is having compassion for the poor people

that have to enter from stage left in my life to beat me up, having compassion for them. You're not going to change them. You don't have to. You can set boundaries with them, but having compassion. Otherwise you're caught up in this karma of negative spiral. And so that's my story. I know that I talked for a long time, but I love telling you that story. 

Shiv: No, I love it. I think a lot of our listeners have experienced some of this already, the need to get to self-compassion and go up those levels. But a lot of them probably are like, ‘I have no idea what you're talking about’ because they haven't yet experienced that being at level one or two of being in constant fight or flight. I think maybe the first and only time a meta meditation was ever done at Hopkins was in that room when you were leading it for the entire group of surgeons and residents and interns. 

I would love to just hear briefly, like, what does your own wellness practice look like day to day? Because I’m sure you go in and out of different things. You do maybe some yoga retreats or those meditative practices. Are you doing meta every day? I'd just love to hear how you lead by example, because you're teaching this stuff. And one thing as an aside, the breath work you shared from James Nestor, who was also a guest on the podcast… 

Dr. Mackinnon: Oh, lovely. Oh, wow. Love his book. Love it. That's a great book. Yeah. And also the epilogue with the pranayama practices. That was wonderful. 

Shiv: Yeah. That's the most useful part of that book. If you only have time for one chapter, just read or listen to that chapter and just try a couple of things in there. But yeah, what does your wellness ritual look like, if you don't mind sharing it?

Dr. Mackinnon: My wellness ritual is different than it was when I started in 2003. My daughter got me into yoga and it's different now. I would recommend if people don't have one, then to just, as you said, listen to the epilogue with the breathing practices and start with that. All of the meditation is just to make you mindful so that you can be in the present moment, not otherwise in the default place, which is in the past or the future.

So, it's just whatever practices you do. It's kind of hooking you so that eventually you can be in

the moment a lot. My practice right now is being aware when I am not in the present moment. Tara Brach, The Sacred Pause. It's like putting your finger on the pause button and as soon as your finger goes on the pause button, you're at level three because you're slowing down. And Tomlinson said, if you want to take a fast reactive medicine, then you should slow down. If you want something to help you quickly, slow down. So by recognizing those fight, flight, fear, anxiety, sadness, anger feelings…as soon as you recognize that, you pause. And in that moment, you slow things down. And in that moment, you investigate what you're really feeling and then you ask yourself, can I sit with that feeling? Then you sit with that feeling and then you give yourself some compassion and that's level four.

So now, you've been level two, you go to level one. You might go to level two, you stay at level one. You're in this cursed little dark spot. Take a breath. Okay, I’m at level three now. You pause there and you investigate what you're feeling. As you say the next rule -- this is Tara Brach's rule, too -- you say, what am I feeling? What am I really feeling and what important thing has been crushed or compromised? What value? What do I value? You're pausing, and this can all happen very quickly. 

Pema Chodron says you can get a good enough slow down to not be reactive with the default response with three slow breaths. She has a great little book called Taking the Leap, also a great book on meditation. So, I would definitely recommend her. So, you slow yourself down, you give yourself that compassion, and then you're at four and then right above you is peace and calm where there's only something to learn. So my practice is that. It's moment to moment to moment now.

I definitely just love sitting for twenty minutes, seeing how reactive my head is, how I can shift my awareness wherever I want. I have control of that and really trying to find the present moment. And then below the present moment, doing these things like, okay, I’m just this wave on a big ocean. This is all the nonsense of our lives, but I’m sitting on this top of this presence, which is huge, which is actually the divine creation of everything, and just floating in there and then doing that breath to sort of dissolve my whole body into this big area. And I do yoga every day in the front hall. I have my yoga mats. 

But I think the takeaway would be, go and do something. If you're even saying, “I think I want to,” explore it. But basically, all it is, is really hooking you in so that you have the mindfulness of what you're feeling and sitting with that. And then you add the compassion, self-compassion of level four in yourself. So you're going to be okay. Sit with that. You're going to be okay. Are you feeling better? No, not really. Oh, let me hug you a little more. Let me give you some compassion. And then you can say, okay, I feel all right now. Well, then how about we just gear it up to that level five, peace and calm? What can you learn here? There's no failure. There's just opportunity and there's lots of serotonin. There's no anxiety if you're on this dose of neurotransmitters, of serotonin. Yay. And those neurotransmitters are so delightful, and the adrenaline and cortisol is so not delightful. 

One other quick thing I would say it's fun to know is if you want to show that this works, you can mouth breathe so your mouth is dry. We all tape our lips, right? We do what James Nestor says now. But if you mouth breathe, your mouth is dry. And then you start to inhale, slow….one, two, three, four, five. And then exhale, slow….one, two, three, four, five. You can do the box breathing. You can stop at the top between inhale and exhale. That's a nice area to hang out. You're in between the inhale and the exhale. What is going on there? I think it's a real quick way to get to the portal of seven is to sit between the inhale and the exhale. But when you're holding your breath or exhaling, you're driving the parasympathetics, which will also increase your salivary glands. You can get this, as physicians, you can get this awareness. This works. I’m getting all this saliva in my mouth just doing nothing but slowly inhale, holding, slowly exhale, holding, slowly inhale. Inhale is sympathetic, but you're doing 25% of sympathetic and 75% of parasympathetic. And then the saliva is going and you know what's happening. 

You know, you're downing the cortisol and adrenaline and you know that when you're at the level one and two, you are at the survival brain, you are fight, flight, freeze. This is limbic reptilian brain. And if you want to do well in your exams or your in-service or your boards, you're not going to do well if you're fight, flight, freeze. So you need to do this. If only to explore it. If only if you want high performance in every aspect of your life. That's the only reason for you actually to listen to any of what we're talking about. Or read Bruce Schneider's book, Energy Leadership. But if you want some high performance in every part of your life, this is the trick. It works. And I am so grateful, like I said, for living in the desert of the burnout of those few years. I’m grateful for that.  

This is my mission. I have also studied Roger Everts, who talked about diffusion of innovation and the tipping point. The outliers came from Anders Ericsson and the tipping point came from Roger Everts' book. The tipping point is when you get 15% to 20% of the group to think this is a good idea. If you don't, it's an idea before it's time. It's like nerve transfers in 1911. But if you get to that critical 15-20% of the group buying in, we've got sixty some percent of us burned out. Those people, we have it. The only problem is that in the hierarchy in some situations there's retaliation if you complain. But here's the thing…I’m untouchable now. I just care so much about this that I don't care about somebody saying bad things about me or, you know, kicking me out or taking away my this or that or whatever, because this is in my mind. You can close my lab. You can take away the people working with me. You can take all of this stuff away and you can't take away what's in my head and in my heart.

So, this is something I can do. One of the first things you said is scale it up. You can scale this up. You can get Bruce Schneider on your show and scale it up and save the world because we need physicians. 40% of medical students now are not really interested in practicing clinical medicine, so this is trouble. And also with the Balanced Budget Act from 1997, there are no more slots for trainees and the population in the United States going up like this and the number of administrators going up 3,500 in the same period of time, but no more physicians. 

We need to change the culture and fix the climate and get it to a point where you can take the Hippocratic oath, which says if I don't agree to look after the care for prince and slave alike, I should die. If I don't follow this oath, I should die. So, we need to get back to that. This is a way to do it. It's only seven steps. You have to memorize a few things and then off you go and then you'll find it yourself. You'll find your practice yourself because these neurotransmitters are so lovely and the results from living at those levels are so wonderful in every part of your life that you want that. That's what you can be addicted to…your own serotonin, your own endorphins, your own anandamide, and your own oxytocin. 

Shiv: I love it. I love it. I mean, again, one of the reasons I knew I had to invite you to the podcast right after your talk was because you're super credible. I've heard some of these messages and many of us have heard them from, you know, what people would call hippies and stuff, right? Like it's derogatory, even though there's so much wisdom there. But the fact that you've already achieved the pinnacle of what people who go into medicine want to achieve in terms of pioneering surgeries and publishing thousands of papers and having labs and having tenure and all these things, and then you're able to also come to this from a personal but also research perspective. I've meditated and done a lot of breath work, but I've never even heard the idea of seizing upon your salivary glands to see if physiologically, if it's actually working, which is a cool thing that comes from listening to someone like you, who's combining your medical expertise with your, ‘East meets West’ kind of medicine that you're doing here.

Dr. Mackinnon: You know, can I have another three minutes? Because there's one other thing I want to tell you. A level five idea came right now from level sixing with you, connecting with you, and then dipping down a little bit into level five where ideas are everywhere. Get a load of this. I like the idea of taping my mouth together. My husband thinks it's great. I say I’m going to tape my mouth. Is that okay? Anything else you want to talk about? No, go ahead. Tape your mouth. This is good. So, when I tape my mouth, you don't have dry mouth. And I’m wondering if having all that saliva moving around there…if that helps the parasympathetic by actually the breath. Hello! We should ask James Nestor that, but like, should we all be taping our mouth just so we don't go to the dry mouth so we can really make our saliva happy with the parasympathetic stuff?

But this is what I want to tell you, and then I promise I'll stop talking. The whole story is serendipitous. So, in 2015, I was going to the Nerve and Hand Meeting in the Bahamas. I got on a plane and there's three seats and I’m sitting here and another woman is sitting here and there's someone in between us. I started talking and asked, “So what are you doing?” She said, “Well, I’m going to the Bahamas for my 50th wedding anniversary.” And I said, “By yourself?” She said, “No, my husband's over there.” We hadn't taken off, so I got up and asked the woman sitting beside her husband if she would you come and sit with me so this woman can sit with her husband. It's her 50th wedding anniversary.

So they do that. The woman sitting beside me was another change your life person in my life. She was like an angel coming in my life. She's from California. She was going to the Bahamas. too. I was going to this place called Paradise Island, which was really like, not well-named. But just down the beach, about like maybe a quarter of a mile, was this ashram retreat, a yoga retreat that had been there for forty-six years. She was going there for a week. She was a psychologist for child trauma and she told me about this book by John Alexander. She also was talking about how you can manifest, and that's what John Alexander kind of talks about.

The woman beside us sort of got in our conversation. Her husband of more than fifty years had just passed and she was going to the Bahamas to try to recover a little bit. So, the two of us -- this woman who's just lost her husband -- and me, who, you know I was worrying about my grant. It was January. I was going to find out in February whether I'd get my NIH funded grant and I was sixty-five-years-old. But anyways, this woman helped both of us. She's remarkable. 

So, I get to the Bahamas and at this place I’m staying at you’ve got to go through casinos with smoking and lights and noise. And it was like horrible. So, she invited me to go down and do yoga with her. So I go down to the beach and I’m doing some yoga at their little ashram thing, and then there's something going on with this very thoughtful person talking and I coming back to my hotel. It's dark, and I sat on the beach and I did what John Alexander says in his book, which is Proof of Heaven. He's a neurosurgeon and he had a stroke and almost died, but didn't. He went to heaven and came back. But he talks about -- and so do lots of people, like, everybody that talks about it - putting yourself in the future and knowing in the future exactly how you're going to feel, and then, like, sit literally being there. 

So I said, okay, I want this grant funded and I was still wondering why do I care? Why am I so attached to this? Like, I’m so accomplished. When can I get off this? So, I sat on the beach and I thought, okay, do you want the grant? And I sat there and I thought, what will you feel like when it gets funded? And I felt great. Then you're supposed to ask yourself why is it really that you want this grant funded and put yourself there and ask you that. And you know what my answer came to me? So I can talk about things that I care about from the position of being a neuroscientist and people will listen to me. And I burst into tears on that beach, in the dark. 

It's exactly what you said. I can be credible because my H index is off the charts and I've got seven hundred publications and thirty years of NIH funding and ten years of MRC funding in Canada. I’m smart, and I have focused in one area I’m passionate about so I have accomplished a lot of stuff. And I’m married to Alec Patterson, who is more accomplished than I am, you should have him on the podcast. So, like, I’m free to do what I want to do. 

I've been blessed with four kids that are wonderful, that are around play all the time. I was around play, level six play, and now I’m around eleven grandchildren, level six play. I have been so blessed, but that was a shock to me that I knew I wanted it, but I didn't know why. And then when I did that manifesting, it just came to me from level seven, for sure, so I can teach this to other people so they don't have to suffer in pain and fear and anxiety, because I know how to be up there. 

But here's what I didn't know in 2015-16. I didn't know what it was like to be down there. And I got that as a gift in 2018-19 and then right crazy that like the fires were burning in 2021. Oh my gosh, it was

Nuts. It was so nuts. It was so horrible and so nuts I couldn't even believe it, but now I know I needed to get down there in order to be able to be there with people that are there. That I've been so privileged in so many ways, every way. So, that really resonated when you said you can talk about it from credibility.

Shiv:  Yeah, wow, that's a great story. Certainly, those types of stories stick with you and I would say that self-awareness is a key theme. We all do these things without recognizing that the things we do are often just desires that society or our parents or someone else places on us or just, you know, we're on a treadmill in this momentum, right? That's why a lot of people wake up one day after ten years of practicing and realize they actually didn't want to do this exact thing the entire the rest of their life. Unfortunately, that happens to them. They have the breakdown to break through.

I've already taken you way over the thirty minutes so just to kind of bring this to a close I have two last questions, One is, this whole podcast has been full of advice and book recommendations that you've given our listeners, so this may be a very redundant question, but I have to ask because I’m sure you've answered this many times for your own children and grandchildren and your trainees. What are some of the key pieces of advice you want to leave our listeners with as far as approaching their careers and lives?

Dr. Mackinnon: Well, okay, I’m glad you asked me that. I was kind of hoping. I have mantra boards. Greg Kelly who's an artist in Virginia, made these for me. This is my first one and it is “non carborundum illegitimus” and it's got my dad's little signature there, Don Lachlan Mackinnon. He gave me that when I was a teenager. It is sort of pig Latin for, “Don't let the bastards get you down. And now I know it is ‘don't let people that level two you, get you down.’ When he told me that, it really stuck with me. I don't even know why, but he told me that. 

The other thing I do remember he told me, though, was when I had a 95% percent he asked me where the other 5% went and I remember thinking that's weird. Come on, I’m like top of my class you're kidding, right? But it stuck with me. So, that message stuck with me…like that ‘you’re not good enough kind of thing,’ or ‘are you good enough yet.’ 

Here's the big thing, though. A big thing is we have been given that message from people that love us, that we've got to do well, and we interpret that as we aren't good enough yet. And we have to be like oriented towards accomplishing something and outcome related. That's very level one and two and then we have to stop doing that. So, it gets us you know those books were saying ‘take you here but not there’ or ‘go fast alone, go far together.’ So, this level twoing that we do ourselves from the culture and the people that love us…we have to be aware of that and stop it because it got us here and it is not going to get us where we want to go. 

So in 2006, I got this mantra which is “Do the best you can, let the rest be done for you.” This is Greg Kelly's work again. Lovely. Do the best you can let the rest be done for you. I got that in 2006 when my sister was here and she had some medical problem and I was just exhausted and she was exhausted and went for a yoga class. I wanted an active class. It was a yin class and I thought I’ve got to get out of here and the teacher said “Do the best you can and let the rest of be done for you.” Same thing. Do the best you can. You get into the positions we're in because we did stuff and then let the rest be done for you. That's heresy but that's important. Let the rest be done for you and say thank you. 

And then in 2018 when I started to suffer I said, “forward, fearlessly, courage, curiosity and trust” and these were my five words. Like Rumi, I couldn't add anything to it or take anything away. That was his definition of beauty. So, forward, fearlessly, courage, curiosity and trust. That's my advice from 2018. 

And in 2022, oh boy, that was now I've been through this burning out thing so it was, “find joy, be kind, do good, reject me.” And now last year it was this message that just came to me and that was, “Not only am I good enough, Susan, you're blessed.” And then I don't know if I heard the words “act accordingly” but yeah. So those are my wisdoms. That's it, but those are the things that are important to me. So, we're all blessed. The other voice said, “Not only are you blessed Susan, everyone is blessed. They just don't know it.” So, I would say everyone is blessed and knowing you're blessed, act accordingly.

Shiv: Wow. You are the first guest we've had who not only had great concise advice but also knows the time when I came, why it came to them, the stories and then also actual like, a slide presentation. We normally just do this audio-only but I feel like we should post the video just because you went through that. So that's great. I mean, so much advice is contextual but you've provided the context for why you are giving it. I think a lot of people who give advice assume that because it worked for them, it's going to work for everyone and, you know, that's not the case with advice.

Dr. Mackinnon: That's sort of like mentoring. You know and so you can. But coaching -- which now I’m a

certified coach from Bruce Schneider’s IPEC -- it’s that the coach has the expertise and all you do as a coach really is just give a space for them to start thinking about these things because they're so busy they never do that. It gives them a pause. Being a coach is really just putting your finger on the pause and then letting it go. Absolutely. So, I'll give a shout out if anybody has words or mantras and they want a mantra board, contact Greg Kelly in Charlottesville, Virginia, our artist friend. He can make them up and you can have your little pile of boards, too. 

Shiv: That'd be great. Maybe we can get the link and then post that in the show notes.

Dr. Mackinnon: He would actually be a good person to be on a podcast. I think he has done podcasts. He's quite a character. 

Shiv: We'll take a look.

Dr. Mackinnon: Artists are very creative. They're in the same kind of plane that creativity is at -- level six. Okay, I gotta let you go. This is ridiculous. 

Shiv: Not at all, Susan. Thank you so much. It’s really, really a pleasure to have this time with you and also once we have the video, we'd like to share it widely. So, thanks again in advance for that.

Dr. Mackinnon: Great, thanks for doing that. All right. Let's get to that 20%. Change the culture, change the climate. We'll all be happier and the hospitals will make more money not less.

Shiv: And with that I’m Shiv Gaglani. Thanks to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.