Peregrino Physician Coaching. Life Coaching for Physicians.

Hippocrates Shrugged

October 2023

I came across an article not long ago about the Hippocratic Oath. Hippocrates was the true pioneer of ancient medicine, and original fragments of the oath attributed to him date back to the 3rd century. Both timeless and a product of his times, the earliest versions of the oath begin by swearing to a variety of Greek       gods and goddesses that as a practitioner of the medical arts certain       standards would be honored. There have been revisions through the centuries, and the modern version  still used in graduation ceremonies dates to 1964. It is long, and if your memory is no better than mine, you probably mostly just remember that it says something about doing no harm.

I recently read the modern version of the Oath again after all these years. I was impressed by the fact that while the importance of scientific gains are emphasized at the very top, the Oath primarily lists the many ways that we hold our       patients’ holistic wellness and dignity first and foremost, and how both our service to humanity as well as the meaning and joy we find in our work are derived from being healers. It is equally striking how the current medical environment that we work in, usually controlled by people who have never taken this Oath, makes the things that are of paramount importance in the Oath almost impossible to fulfill at times. 

In a busy, overbooked clinic seasoned liberally with meaningless administrative tasks and onerous charting, just how easy is it to honor “…that there is art to       medicine as well as science and that warmth, sympathy and understanding       may outweigh the surgeon’s knife or the chemists drug”? How often do the       pressures of efficiency make it difficult to "...remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick”? Hippocrates was describing healing here, and it is embarrassing to try and explain to anyone outside of medicine, or to ourselves, how it is that honoring the Oath was allowed to become so difficult, how economics has been allowed to trump values, creating what       we now call moral distress. 

There was a popular book in the 1950s, Atlas Shrugged. The author, Ayn Rand, derived the book’s title from a reference to Atlas, a titan in Greek mythology who is remembered in myth and imagery as the giant who held the world on his shoulders. In the book, two characters have a conversation in which one asks the other what advice he would give to Atlas if the greater his effort, “the heavier the       world bore down on his shoulders.” The other character replied that the advice he would give would be “To shrug.” Though the title is intriguing, I never read the book and It’s unclear whether to shrug means for him to express indifference or defeat to a hopeless situation, or if it means to not give up and to force his shoulders upward against the immovable force. This book title came to mind when I was considering the load that we physicians carry on our shoulders these days trying to honor the Hippocratic Oath that we all swore to in a more innocent time and how even Hippocrates himself might respond. 

There is a story about a Zen master teaching someone about Zen over a cup of tea. As he was serving his guest tea, the Zen master holds the teapot over his guest’s cup and begins pouring. The cup fills, then overflows, but the Zen master       continues to pour tea into the overflowing cup. Finally, he sets down the       teapot and asks, “Now, can you put more tea into the cup?” The horrified       guest replies, “No! It’s overflowing.” The Zen master replies by emptying       the cup and placing it back in front of his guest. “Now the cup has been emptied and is ready for you to fill it with something new.” 

Our lives in medicine are often overflowing, both with things critically important and with things that are utter nonsense. It’s the world we live in and the way we allow ourselves to live in it. Only when we realize this and can empty our cup       just enough to make room for things that are essential and true and lasting, things that we swore an oath to, that our lives in medicine might change. As Hippocrates promised, if we act to preserve the finest traditions of our calling we may “long experience the joy of healing those who seek our help.” 

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Hospital Meatloaf, Yoda and Letting Go

Not too long ago I was struggling over a plate of meatloaf in the doctor's dining room. Fortunately, the table conversation was better than the food. Somehow it turned to how early career doctors tend to mirror the culture and clinical habits from their training program and how it often takes years to unlearn habits that don't serve us well in the long run, particularly habits related to work-life integration. Training programs are more sensitive to this now, but the economics of medicine are an inescapable reality we must navigate, and in our counseling program I hear of the struggles that some physicians experience to sustain meaning and joy in their work and healthy relationships and peace away from work. Students are now referred to as “learners,” and I pray that most of what they learn will serve them well after training, but it makes me wonder if we should all eventually progress from learner to “unlearner” and whether both states aren’t valuable in their own way.

There is much in popular psychology literature about unlearning. J.R. Rim famously noted, “Intelligence is what we learn, wisdom is what we unlearn.” Even the icon of pop culture wisdom, Yoda, of Star Wars fame, advised Luke that in his spiritual path forward, “You must unlearn what you have learned.” Ask any therapist – unlearning is foundational to new beginnings.

I revisited Richard Rohr’s, Falling Upward, recalling that a theme in much of his writing is about unlearning. As he puts it, “All mature spirituality in one sense or another is about letting go and unlearning.” Rohr holds that life really consists of two phases. The first phase is the egocentric phase, what he calls the “survival dance,” wherein the emphasis is on developing identity, success, security, and image cultivating. This is not to say this phase is bad – it is all necessary, and though there are many struggles, most often great good comes with it along with important learning, experience, love, and joy. Rohr holds that the ultimate task of this stage of life is building what he calls “a proper container” that will be needed in the second phase of life.

In the second phase of life, those learned survival and identity tasks fall into the background, habits that supported them are questioned – unlearned – and the container created earlier is emptied then filled with awareness and appreciation for deeper meaning. Things that the soul thirsts for, that were missing earlier, can now be fully discovered. It is a time of “letting go.” Rohr calls this the “soul dance,” Zen masters call it seeking the face you had before you were born. Some religious traditions call it being reborn. Some note parallels with the common literary structure of the hero’s journey. In any sense, it is a shedding of baggage accumulated earlier for something better. It can occur subtly or abruptly and depending on your early life experience it may show itself at any age, or in some, it may never become evident.

There's no good story, nor anything profound in all this, just an observation made over a half-eaten piece of meatloaf. The thing that we call our life journey may be a journey to the true self, to spiritual wholeness, or to God, but like any hero’s journey, it is always a journey home, the home your soul longs for. At some point, young or old, most will find themselves as lost as Dante: “Midway on our life’s journey I found myself in a dark wood, for the right way was lost.” It will be wise to remember at that point the importance of unlearning, of letting go. It is in the homeward part of that journey where rather than paddling furiously, we might just drift in the current and finally look up to enjoy the scenery that was there all along. And on the long journey home, as Mary Oliver urges, “If you suddenly and unexpectedly feel joy, don’t hesitate. Give in to it.”

Brian Sayers, MD

2023

The Bear

In a recent episode of the TV show Lucky Hank, Hank and his wife are entertaining his not-so-beloved academic coworkers. Table talk is degenerating, and to change the tone of the conversation Hank's wife suggests a table game. She asks each person to give their two “happiness numbers,” the first one being their “percent happiness,” the second number asking how low that happiness number would have to get before they would make real change in their lives. The game was a terrible idea for a party, but it made me think: these last few years, the threshold for change for many of us has changed, often, but not always, for the better.

We have seen many versions of change around us, and you likely went through some version of the process yourself these last few years. Many of these transitions were admirable and involved careful discernment and often no small amount of sacrifice and courage. Reimagining work and changing an unhappy practice situation or career direction, taking a sabbatical from practice to catch your breath, cutting back days or hours to be more present with family, shedding a bad habit or bad relationship are frequent examples.

For many, there were other changes, often for the better but sometimes not as well thought out − pandemic pets, retiring early, or the greener pastures of a vacation home or moving far away. Many, if not most, share something in common − leaving something that makes us sad, or anxious, or unfulfilled in search of something better. Like some of you, over the years I have made my share of missteps in seeking change. But in the moment, in real time, how do we tell the difference between necessary change and just running away? We are, after all, hardwired to run away from things that threaten us.

In his cautionary essay, Wherever You Go, There You Are, Jon Kabat-Zinn explores the human tendency to run away. “The romantic notion is that if it's no good over here, you only have to go over there and things will be different... Change the location, change the circumstances, and everything will fall into place; you can start over and have a new beginning.” But he points out “you cannot escape yourself, try as you might...” He calls on us to consider that true change comes from the inside rather than from changing things on the outside, even when it is easier to run. Sometimes, that means standing our ground.

David Whyte describes it in another way: “Wanting to run is necessary, actual running can save our lives at crucial times but can also be extremely dangerous and unwise, especially in the presence of animals that are bigger, faster and more agile... In the wild, the best response to dangerous circumstances is often not to run but to assume a profoundly attentive identity, to pay attention... and not to assume the identity of victim.” Standing our ground, confronting perceived threats, resisting the urge to flee, is sometimes the hardest work we face as adults. But when it is time to run, the key, I think, is to make sure that we are running towards something and not just away from something.

Restless in that first year after the shutdown, I found myself in Colorado for a few days of hiking, hoping in vain to briefly forget the pandemic. One gorgeous fall afternoon, a few miles from the trailhead I came around a bend and found myself not more than 20 feet from a black bear. Both of us froze. I tried immediately to recall the recommended response to this situation, and based on that highly flawed recollection, I stood very still, made eye contact with the bear and… sang. Somehow, I thought there was supposed to be talking or quiet singing, though where I got that notion, I have no idea. There was a Bob Dylan song, Don’t Think Twice, It’s All Right, that I couldn't get out of my head that day, so I quietly sang to the bear… or maybe to myself. The bear stared at me for a solid minute, then turned and trotted off. Perhaps the defining moments in our lives are when we make a stand and when we run away. Admittedly, it was more paralysis than bravery, but in that moment, I was just fed up enough with bears and pandemics that I continued my hike, even with the sure knowledge that there are more bears in my future.

Brian Sayers, MD

2023

Mending Wall

At a volunteer clinic years ago, past our usual quitting time they kept letting patients check in. It’s an evening clinic and after a long day I was getting grumpy about staying late. A colleague and fellow Methodist set me straight (or was he just messing with me?) by reminding me of a quote often attributed to John Wesley, “Do all the good you can, by all the means you can, in all the ways you can, in all the places you can, at all the times you can, for all the people you can, as long as ever you can.” Thanks to that night, I often remember this call to infinite service ‒ and not with fondness. While it’s low hanging fruit for a sermon, it would likely elicit groans in a doctor’s dining room. Physician wellness today focuses on recognizing healthy boundaries.
 

It’s been on my mind again as I read Melissa Urban’s book, The Book of Boundaries: Set the Limits That Will Set You Free. Urban’s theme is that setting boundaries in all phases of our lives leads to peace and happiness in relationships, work, and with ourselves. Many of us go through life unhappy in one or all of these domains because we fail to declare boundaries, instead assuming those around us will read our minds then honor these invisible lines. She notes three stages of setting boundaries: discerning what boundaries are important to us, then clearly, kindly, and verbally informing those affected, and lastly by enforcing them. She emphasizes that setting boundaries is an act of love ‒ it ultimately strengthens relationships and makes us more effective in the workplace. Defining boundaries should come from a place of love ‒ the point of them should never be to control or change those around us, rather to define behaviors and actions we will or won’t tolerate in our own lives.
 

Some boundaries for doctors are obvious: unprofessional relationships with a patient or employee ‒ anyone with whom we have an unequal power dynamic ‒ or treating those with whom we have a relationship that might cloud our medical judgement. But Urban goes far beyond these obvious examples. At work, many, if not most, of our colleagues are asked to see too many patients, do too much work at home, and have too little control over their schedule, often at great cost to loved ones and themselves. Ironically, while we are confident and clear with our patients, we may feel strangely powerless to set boundaries for how we navigate our workday, or fail to enforce boundaries we do set, then wonder why we are miserable at work.
 

Setting boundaries with friends and family can take many forms ‒ anything that puts us repeatedly in situations we find awkward or against our values. Toxic relationships with family or friends (“vampire friends”) are just not worth the effort if they perpetually ignore boundaries. We hear all too often from marriages, especially those with young children, the laments of unequal parenting duties, unequal “me” time, too little “we” time, complaints of dissatisfaction with all kinds of issues related to physical and emotional intimacy. Our experience in the PWP counseling program speaks strongly to the fact that physicians seek help related to relationships as much or more than issues solely related to their work, issues that Urban argues are by and large related to important but undeclared boundaries.
 

Perhaps most important are the boundaries that we should set for ourselves. It can be simple things related to diet, exercise, how much time we spend at work, or how much time we gift ourselves and loved ones ‒ boundaries we need to keep mentally and physically healthy. The inability to say no is a common personal boundary we often neglect. Urban points out that if we take on too much from all that people ask of us, it is not their fault. It is our fault for not setting personal boundaries and then following them. As Urban points out, if you never say no, “…they are never going to stop asking. Why should they?”
 

Robert Frost’s 1914 poem, “Mending Wall,” contains one of the most frequently quoted lines in American poetry: “Good fences make good neighbors.” The poem’s interpretations are nuanced and evolved in the era of world wars that followed its writing, but the line itself is timeless. Perhaps boundaries, like good fences, when brought with love help us live in harmony and peace. Boundary setting is a sign of maturity and respect for the important relationships with ourselves and others. As Urban notes, “...Boundaries produce the shiniest version of ourselves. They say, ‘I am worth protecting.’”
 

Brian Sayers, MD