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Your Best Life: Ancient Toltec Wisdom for Resilience

Kelly, John D. IV MD1,a

Clinical Orthopaedics and Related Research: June 2017 - Volume 475 - Issue 6 - p 1544–1546
doi: 10.1007/s11999-017-5344-3
Your Best Life

1Perelman School of Medicine at the University of Pennsylvania, 34th and Spruce St., 19104, Philadelphia, PA, USA


Received March 27, 2017/Accepted April 3, 2017; previously published online April 7, 2017

A Note from the Editor-in-Chief:

I am pleased to present the next installment of “Your Best Life,” a quarterly column written by John D. Kelly, IV MD. Dr. Kelly is a Professor of Clinical Orthopaedic Surgery at the University of Pennsylvania. His column explores the many ways that busy professionals—surgeons and scientists—might find peace, happiness, and balance both at work and in their personal lives.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and RelatedResearch® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research® or The Association of Bone and Joint Surgeons®.

In his celebrated work, The Four Agreements [7], authors Don Miguel Ángel Ruiz and Janet Mills masterfully communicate the powerful wisdom and venerated spiritual truths of ancient Toltec civilization and culture, which gained popularity in central Mexico between the 10th and mid-12th centuries CE [2]. These truths are encapsulated into four moral imperatives necessary for the attainment of inner peace. The adherence of four “agreements,” or promises one makes with oneself, can help an individual live a fulfilled, tranquil, and peaceful life.

My wife recommended The Four Agreements at a time when I needed to change my perspective on life; my “well was dry” from trying to be all things to all people. After reading this timeless work, I recognized that my life had strayed from the book's core principles.

Unfortunately, I know of many colleagues struggling to cope with similar feelings. In fact, more and more US physicians are experiencing burnout [8], and maintaining a resilient disposition in the workplace is a growing challenge for surgeons.

While we must accept that there are circumstances we cannot change, we do have the power to determine how we respond to whatever life presents us. How physicians respond to an event, and the manner in which we choose to see our world once the event passes, is the key to our overall wellness and happiness. The Four Agreements offers a template to keep one's life in alignment with enduring and timeless principles that foster deep and enduring inner peace. Let's take a look at each one.

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Agreement 1: Be Impeccable With Your Word

The word “impeccable” is derived from the Latin word impeccabilis, meaning “not liable to sin.” According to Ruiz and Mills, the first “agreement” we need to make in order to live more fulfilling and joyful lives is to never use our words to sin against another or ourselves. Simply put: Words matter. A single critical remark can destroy the mood of an entire evening. One sarcastic comment can disrupt the joy of an entire family. We see this at work, as well. A recent CORR® editorial [6] pointed out how much of the words we use influence the care we give, often unintentionally. For example, phrases like “the patient failed conservative treatment” may be perceived by patients as inappropriately critical; if it seems overly sensitive to look at language in this way, consider the parallel construction “he failed his engineering exam.” In contrast to the engineering student, the patient did not fall short, and did nothing wrong, but the language implicates that perhaps (s)he did.

Likewise, derogatory comments directed against colleagues will cause them to think less of us and direct negative energy our way. Ultimately, harsh words are not one-sided—we harm ourselves with them as well, subverting our own happiness. When we find fault in ourselves or indulge in self-reproach, we violate the first agreement.

In sharp contrast, one kind word or compliment can transform someone's day [3]. Resilient individuals are mindful of the power and influence words have on others and themselves. Ruiz and Mills emphasize that only loving words are truly meaningful and self-criticism or self-flagellation merely emanate from our wounded selves.

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Agreement 2: Don't Take Anything Personally

Ruiz and Mills explain that what others say or do to us is actually about them, not us. We should not take negative comments or actions directed against us to heart; we are not to buy into another's illusory belief system about themselves. Unsavory words or actions directed by one individual towards another are about the pain of the sender, not the receiver.

Consider the surgical patient who swears at his surgeon postoperatively, exclaiming that the narcotics were not provided in a timely fashion. It is best to pause and understand that the pain of the incision, not the patients’ character, has prompted this behavior.

Closer to home, consider the loneliness and heartache the spouse of a surgeon feels when his or her loved one has been away for consecutive on-call nights. When the surgeon finally returns home, only to be greeted by acrid comments, it is important to pause and recognize that your spouse is merely witnessing and experiencing his or her loneliness. Although we should protect our personal boundaries, there is no need to become defensive against personal assaults; that only legitimizes the attack and feeds it energy. We must recognize that harsh words directed against us are the byproducts of someone else's internal programming and suffering [5]. As Eleanor Roosevelt said, “No one can make you feel inferior without your consent.”

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Agreement 3: Don't Make Assumptions

The great psychiatrist Aaron Beck has described numerous cognitive distortions or patterns of dysfunctional thinking, which beset a mind afflicted with negative emotions [1]. Chief among those distortions is “mind reading.” This distorted thought pattern tricks us into believing that we truly know the thoughts of others, and, in most cases, we assume the opinions of them are directed against us.

In reality, we never truly know what another person is feeling. When we make assumptions about patients based on their appearances or even their histories of drug or alcohol use, we impose barriers between ourselves and those patients, which we then must overcome. Although making such assumptions is a natural human tendency, many patients who appear rough or unconventional are as sensitive as anyone else. Whatever we can do to avoid beginning our encounters with patients who look different by allowing our assumptions to drive our impressions will make it easier to connect with them.

Ruiz and Mills affirm the power of inquiry. Whenever there is a discrepancy or disagreement, ask for clarification. This especially applies to your most intimate relationships. For example, roles and goals of each marriage partner should be discussed and expectations of each other clearly conveyed. Many a domestic argument will be averted!

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Agreement 4: Always Do Your Best

The final agreement will afford you the ability to incorporate the first three habits into the framework of your life. In every event, simply do your best, and there will be no room for regret, remorse, or self-judgment.

Always doing one's best can help us disengage from the mindset of engaging in an activity solely for a reward. Ruiz and Mills encourage us to pursue those things we love, and not reduce a task to simply a means to an end. Engaging in actions that generate benefits to others are more sustaining than those seeking personal gain.

Endeavor to approach each and every activity with calm and love, offering your best inspired (not compulsive) effort. Dissociate from potential credit and pursue interests with love. You will be astounded at what you will achieve.

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Tomorrow, Try This

  1. Agree to these four contracts with yourself. They will help you guide yourself to a more-fulfilled life.
  2. The next time someone directs a less-than-kind word or action against you, pause, breathe, and create some inner space between the event and you. Then, respond in a way that is loving to the offender and yourself.
  3. Write down ambitious but realistic goals for yourself. When we hit our targets, our confidence and capabilities grow [4].
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1. Beck AT. Love is Never Enough 1989;LondonUK; Penguin.
2. Cartwright M. Toltec civilization. Available at: Accessed April 3, 2017.
3. Diener E, Oishi S. The nonobvious social psychology of happiness. Psychol Inq. 2005;16:162-167 10.1207/s15327965pli1604_04.
4. Martin JJ, Gill DL. The relationships among competitive orientation, sport-confidence, self-efficacy, anxiety, and performance. J Sport Exerc Psychol. 1991;13:149-159 10.1123/jsep.13.2.149.
5. Neuman JH, Baron RA. Workplace violence and workplace aggression: Evidence concerning specific forms, potential causes, and preferred targets. J Management. 1998;24:391-419.
6. Ring DC, Dobbs MB, Gioe TJ, Manner PA, Leopold SS. Editorial: How the words we use affect the care we deliver. Clin Orthop Relat Res. 2016;474:2079-2080 10.1007/s11999-016-4993-y.
7. Ruiz DM, Mills J. The Four Agreements 1997;San Rafael, CAAmber-Allen Publishing.
8. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613 10.1016/j.mayocp.2015.08.023.
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