Wisdom and leaving the mind alone: The Buddha Walks into the OR Part 6

After a GLORIOUS two week hiatus (seriously, glorious and completely wild and disconnected for 10 days), I’m back and ready to tilt at more windmills, tie up some lose ends, and finish our review of the paramitas for the OR. So, here were are at Paramita #6, wisdom or transcendent knowledge.

If you review our other 5 paramitas, you find that wisdom contains each of them. Practice of wisdom requires us to use all of the other paramitas; each of them provides a necessary but not independently sufficient foundation for wisdom.

Ouch. That’s hard.

Here’s the even trickier part: prajna paramita is based upon knowing that is beyond subject and object, and is definitely beyond ego. This wisdom has at its core, the idea of omniscience- a way of knowing that transcends all knowing.

That’s very meta, right?

So what’s a surgeon to do with this squishy concept that even those well-versed in Buddhism can’t readily explain (I was so grateful when Susan Piver mentioned that in a dharma talk- it wasn’t just me!)?

Quite simply, leave it alone.

According to Tilopa, the approach to wisdom requires only a few things:

Don’t recall.
Don’t imagine.
Don’t think.
Don’t examine.
Don’t control.

Apparently in Tibetan merely 6 words cover that list.

Or, as Rinpoche has advised us, the way in is just to be with things as they are.

It seems to me that wisdom is Paramita #6 because it is incredibly challenging both conceptually and practically. My goal is simply to make you aware of approaches to wisdom because I am absolutely not qualified to make suggestions about achieving it.

But that doesn’t mean I won’t try to get there…




The Buddha Walks into the OR Part 5: Attention, Please!

It’s almost impossible to look around and not find something in media, in pop culture, in all sorts of places about mindfulness.  Interestingly, it’s not just out there in popular culture; my friend and fellow burn surgeon Sharmila Dissanaike led a session during last year’s American College of Surgeons Clinical Congress on mindfulness.  One of the ways in which she highlights the relevance of mindfulness is around resilience, which we know helps to protect us from burnout and career dissatisfaction.  In short, she sees mindfulness as a tool to expand our resilience and help us maintain our passion for our careers.

Mindfulness is also the 5th Paramita, or perfection.  Mindfulness takes practice, and over time it does cultivate the other perfections. An important feature of mindfulness in this context is the relevance of focus, and of tuning out distractions, in a way that we can concentrate on being in this very moment. As I write this, I’m suddenly struck by the serendipity of Tuesday’s blog on multitasking and cognitive bandwidth; even though I was writing about that from a pedagogical perspective, the key message was how we can help learners gain and maintain their focus so they can be more effective.

Susan Piver discussed meditation in one of her recent Open Heart Project weekly Dharma talks as a tool to unite the first four paramitas. Generosity and Patience both come from a place of opening that requires awareness and observation. Discipline and Exertion are more pointed and fierce, and are associated most strongly with mindfulness because of that focus. By putting Discipline and Exertion to work for ourselves, we are able to open to experiences in a way that demonstrates Generosity and Patience because we have more insight.

As surgeons if we are able to be right here, in this exact moment, then we are able to be more effective in our technical and cognitive work. As people, if we are able to be right here, in this exact moment, then we are able to be more compassionate caregivers for patients and families, and we’re able to be more effective team leaders. As family members, if we are able to be right here, in this exact moment, then we are able to be a more effective mother/ father/ sibling/ child/ parent/friend.

What is in front of you right now?

How can you use this moment to both focus on and open to what is around you?

Imagine the difference that mindfulness can make in your ability to both feel good and do good.

Be here.

Pay attention.

Blogger’s note: Heeding my own advice about being present and paying attention, you’ll have to wait 2 weeks for Paramita #6. It’s time for my summer break!

The Buddha Walks into the OR Part 4: Exertion

In our continuing quest to bring more fierceness to our lives and how we live them, today’s blog will dig into the 4th Paramita: Exertion.

We don’t mean exertion in the sense of running 200 meter repeats in 94 degree heat, even though that’s what I did yesterday evening.

We don’t mean exertion in the sense of working yourself into a state of exhaustion, depleted of all energy.

What we do mean related to the idea of making a joyful effort. Exertion in the Buddhist sense is finding the energy to do all of the things that you do. It’s understanding what your motivation is, and using that to sustain you during those times when your energy wanes. How many of us can think of those days when it’s been a long, hectic day in clinic or in the OR that leaves you completely drained…then you find a thank you note from a patient or their family, or from a mentee? How many times has some small reminder of why we do what we do, particularly on the days it’s not easy, suddenly helped you to hang in there an hour or two longer? Suddenly we find our endurance…our sustenance…our ability to forget about how tired we are and just focus on what we’re doing right here and right now. The slog transforms into a (relatively) joyful effort, simply with one small thing that pulls us back to our purpose and back to the present.

Exertion includes the idea of persevering during failure, and viewing a failure as a step towards success. This recent publication from a Princeton professor has been met with some controversy, particularly by those who hold that you can only afford to catalog your failures if you are viewed as successful. He openly acknowledges that each and every one of his failures in academia has been a building block for his success- and perhaps that in some ways the failures have been more important than the successes. It’s an ideal example of exertion in action (and I’ll confess that I am particularly fond of his meta-failure; I related to it since my Blog is read far more than all of my academic publications combined!).

Exertion, perhaps most practically, comes back to that critical idea of managing your energy so that you can do all of the important things.

Think for a moment about things that deplete you of energy. How many of them orient around fear, doubt, anxiety, not knowing, trying to “force” things to meet expectations? I’ll admit that for me that last piece is critical- it’s often the things I feel like I should be doing to meet some external expectation (real or made up) that drain my energy the most. I’ve learned that any sentence that includes the phrase, “Well, I should…” is an indicator that danger is lurking.  Shoulding all over yourself is inherently a bad idea and if I may give you one piece of advice about this behavior, it would be to stop it.

Now think for a moment about those things that provide you with energy. Some of them are probably quiet and peaceful- laying in a hammock somewhere listening to bird calls, falling asleep in a tent next to a river, meditating. I suspect that more than a few of them are not things that are quiet and peaceful, and that some of them are in fact incredibly challenging from a mental or physical perspective.  How is your energy level at the end of a big, difficult operation when you KNOW you’ve been able to help someone? At a rock and roll show with your favorite band (I’ll humbly suggest a Jason Isbell concert as an example)? At the end of a track workout with 200 meter repeats in blistering heat with friends who make it fun, even when it’s hard (I left mine giggling last night)?

Show up. Work hard. Remember your motivation. Stay present. Mind your energy.

Or, as my favorite running tank says, “Nothing about this is easy. Everything about this is worth it.” If that’s not a phrase consistent with creating a joyful effort, I don’t know what is.




The Buddha Walks into the OR, Part 3: Patience, grasshopper

Every week I’m a little more certain that I’m going to scare some folks off from reading about one of the Paramitas and trying to give it some real-life relevance in the madness that is our world as surgeons. This week, we come to the idea of patience, a quality that surgeons are not necessarily well-known for (deserved or not). I will grant that many of us who end up in surgery do so for some of the immediate gratification that “fixing” things gives us.

So, a question for you: When is the last time you lost your patience? Was it in traffic this afternoon? Was it when a nurse asked you a question you had already answered? Was it in the OR when the scrub tech couldn’t find something in the set that you know is in there? Or was it when you got home and your spouse or child expected your undivided attention and you were just too exhausted from your day to provide it?

(Leading by confessional:  I had a low-level loss of patience with the guy in front of me who seemed paralyzed about turning left out of the parking garage this evening.  I mean, it’s a left turn, not brain surgery.)

It might be a little bit easier to start with what patience is NOT- and it is not being completely nonreactive to things around us. If we are actually engaged with our world, it’s nearly impossible to not react in some way to things that happen.  Instead, the idea of patients is to commit to being intentional, to demonstrating wisdom and compassion- particularly in conflictual situations. To not immediately react in a confrontational manner isn’t a sign of weakness, but is instead a sign of great strength because you have the ability to manage strong emotions rather than reacting to them.

Okay, so we should be more patient. That makes sense.  It’s what people have been telling us to do since childhood.  Forbearance is so very hard.

Surely there are things that we can do to counteract our impatience; sure, counting to 10 or taking a breath is common wisdom, but they’re not an easy default for most people. What if you were able to remind yourself that you are reacting to an expectation or an assumption- a story, as we’ve discussed previously- that may or may not be real? Sure, the stories are fun and interesting and allow us to be creative. And, as we know, the stories are so very often just plain wrong.

So don’t get hooked, and instead stay curious. When is the last time you approached a situation and thought, “I wonder…”? What if you took the situation and wondered about it, perhaps even played with it a bit?  What if you practiced taking that step back that allows you to ask the questions, to stay open?

Most importantly, what if we all applied our patience to ourselves?  Again citing personal experience, I had plans to run tonight (and last night, if I’m completely honest, though I managed to get a weight workout done instead). By the time I got home at almost-8 pm, ate dinner, walked the dog, managed some email, and wrote this post…suddenly, it’s almost 10 pm. No run tonight- and I’m not going to push myself into a Plan B workout either since I wouldn’t be done working out until 1030 (or later).

Does this meet my expectations that I started the day with? Clearly the answer is no.

Do I gain anything by getting impatient with me and beating myself up about being lazy? Absolutely not.  I was taking care of people, and that’s what I do. I don’t have control over everything.

Would I have preferred a workout today, ideally my rescheduled run from yesterday followed by some core work? Yes, I would have preferred that, even if it was 400 meter repeats.

I wonder…what’s the best choice that I can make at this point?

Probably to make tomorrow’s breakfast, read short stories for 30 minutes, then go to bed a bit early.  So, on that note, I’ll give some grace to myself and wish you goodnight.



The Buddha Walks into the OR, Part 2: Discipline

As promised last week, we’ll have a brief series on the 6 Paramitas, or transcendent actions, and how we can use them as surgeons and leaders. This week I would like to introduce you to the 2nd Paramita, discipline.  I know, if generosity didn’t scare you off, this definitely will; but, again, it shouldn’t.

The concept of discipline isn’t the simplistic version that we tend to think of (being a rigid follower of rules) or the austere religious version that comes to mind (no hairshirts here!). In fact, there’s nothing punitive about the concept of discipline as a Paramita.  Instead, it is a sense of rigor, of precision, of crisp boundaries- the sorts of things that as scientists we tend to find quite satisfying. Discipline in this context is oriented around being fully present in the moment and not getting hooked by stories.

Stop for a minute and think about a time that you created an elaborate story around why someone was late to work, why they let you down, why they didn’t do something that you really had your heart set on them doing. Making up stories is our default- it’s simply something that we do, and it’s how we manage information.  Some of us make up more elaborate and interesting stories than others.  As individuals we tend to create different stories based upon which of the “three poisons” tends to be our default; while some of us tend to passion (grasping/ greed), others are aggressive (anger), and others will ignore (head in the sand). Many times, our stories end up causing suffering- sometimes our own, and sometimes in others as we react to our stories (which may be far removed from the truth).  And yes, we use these stories in our personal lives, but let’s be honest…we use them in the workplace too. We make up a story about someone being unreliable because they’re lazy when the truth is that they have a sick child and are struggling to get by; after multiple days of that person not meeting our expectations, we’ll head to our default poison in our interactions with them.

What we need to be able to do in the moment is realize when we’re making up those stories and to pull back from them, both to ease our own suffering and any suffering we might inflict on that person when we react with grasping, with aggression, with ignorance. You know and I know that once we head into one of our poisons, it’s really, really easy to get stuck there. Instead of assuming and making up those amazing stories, we need to stay curious, we need to ask questions, we need to respond with kindness.  Perhaps we even need to look at that person and offer this up (again, with credit to Brené Brown for this framework):

When you do _____, the story I find myself telling is ____.

This very honest takes us out of blaming the other guy, and it helps them understand your framework.

Here’s the closing thought I’ll offer on the topic of discipline:  while discipline isn’t scary and negative in the way we tend to think of it, it is incredibly hard- perhaps the hardest of the six paramitas.  Those stories are just too much fun.