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Viewpoint: Zen and the Art of Emergency Medicine

Hawkins, Seth C. MD

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doi: 10.1097/01.EEM.0000414935.45416.fb



    I have found the lessons are often the same for both communities. The advice I try to share has evolved into a series of seven principles for balanced and successful passage through the phases of medical training and practice. Buddhists are well-known for succinct teachings and principles. I am a Presbyterian by faith, but after a sabbatical in the Himalayan kingdom of Bhutan and other firsthand experiences, I have learned how functional Buddhist terminology and concepts can be for understanding some of the challenges we all face in our careers.

    Although this essay nods to Robert Pirsig's Zen and the Art of Motorcycle Maintenance and with apologies and respect to true Buddhists, it should in no way be associated with that great body of factual information relating to Buddhism or dharmic practice. It is not very factual on motorcycles, either.

    Principle 1 (The Stem Cell Principle): Don't differentiate too early. The concept of stem cells is extremely helpful here. Physiologically stem cells are an extremely complex topic, but conceptually and metaphorically, this is something that even high school students can grasp. Far too often students, trainees, and professionals decide too early what their career path will be.

    The young stem cells among us may be sure they are in a dedicated cell line, inexorably pointed toward a medical degree, until they discover medical social work or physical therapy or public health. Those certain they will become surgeons turn into psychiatrists. Administrators, researchers, and teachers may never have started their paths expecting they would end up as administrators, researchers, or teachers. Go forth and be pluripotent as long as you can. And as you do so...

    Principle 2: Never let someone else define success for you. The pathway of medical training is lined with teachers who are more than happy to tell you what you must do to be successful, or more importantly, what things you shouldn't do. One of the major tasks facing the founders of emergency medicine was to convince the status quo that exclusively practicing in an emergency department was not a "wasted" career.

    Each new medical specialty faces similar challenges. My own residency director Abby Wolfson, MD, while supportive, was skeptical of my plans to forge a career out of wilderness EMS — or "hanging off cliffs," as he put it. Sadly, many enter medicine and choose their medical specialties to satisfy others' perceptions of success. Find your own bliss.

    Principle 3: Don't mess with the pancreas. Truer words were never spoken. This clinical pearl may be the surgical specialties' greatest intellectual contribution to the house of medicine. The runner-up from the orthopedists: "The purpose of the heart is to pump antibiotics to bones." That is a little less compelling. Don't look for deep life lessons here. In true Zen fashion, the only target here is the arrow itself. From your first day of training on, don't mess with the pancreas.

    Principle 4: You will fail. Many times over. The earlier you get this advice, and really hear it, the easier your recovery from stumbles will be. Medicine is a field that aspires to perfection (or damn near close to it), and it breeds that expectation in its students. This is ironic and unfortunate. Medicine, practiced well, is one of the most humbling careers. It may be not that you should be aspiring for perfection but spending time thinking about how you have and will respond to failure. Many of the most important career, research, and personal breakthroughs occur not as a result of successes but in response to failures. As one of our great poets, Kanye West, writes, "I'm trying to right my wrongs / But it's funny these same wrongs helped me write this song."

    But it goes deeper than that. Sometimes failure is just failure, and does not result in breakthrough or growth, and your only response can be to recognize "it is what it is." The earlier you recognize this principle, the stronger and more balanced you will be. Get to be good at failure. A reader of an early version of this essay thought the failure concept should be expanded, and asked, "How does one live with more drastic failures?" My answer: "Exactly."

    As a more personal example, I am a flipper. The University of Pittsburgh, where I completed my emergency medicine residency, has a program where EM residents spend a month each year responding to field emergencies with EMS using a response jeep. Despite nearly 30 years of operations, only a few residents in the history of the program have had the distinction of wrecking the Jeep. Not one to do things halfway, I achieved "flipper" status in 2002, which entailed taking the Jeep airborne through an intersection, performing a 360° airborne rotation, and landing on the wheels. Not my proudest moment, and the failure compounded as the story unfolds, but to prove my point about failure, this taught me my next dharmic principle.

    Principle 5: Leave your radio on (except when you don't). Although I wasn't hurt, when I got out of the Jeep to check on others — I'm relieved to say nobody else was hurt either — I left my mobile radio inside. This meant the dispatchers only knew that there was a wreck with a "doctor down." As the radio silence continued, responders launched from all corners of the Steel City. People who hadn't dusted off their DayGlo uniforms in years were flying to my supposed aid. Flattering, but it took my simple fail to a compound FAIL. So case in point: keep your radio on and on your body.

    This serves as a helpful metaphor for medical careers. EMS physicians like me are opportunists. When our radios are on, we hear about cool things and get to be involved. When our radios are off, we hear nothing. Most of us don't have regular EMS shifts, so our involvement in real-time operations and direct medical control outside the ED is completely opportunistic. Keeping your metaphorical radio on as often as possible ensures you hear about opportunities. Keep it on, except when you don't. Keep your balance. Sometimes you need to turn off your metaphorical radio. My actual radio is off every night and every meal (well, most of them). Metaphorically, you need to tune out the medical world sometimes. This is true at every stage of medical training and practice.

    Two mentors in particular highlighted this lesson for me during my training. Wesley Wallace, MD, one of my all-time emergency/wilderness medicine heroes, taught me as a UNC-Chapel Hill medical student how critical it was to learn to say no. Every time I saw him, he reminded me to remember to say "no." He gave me books on it.

    The guy is like the Nancy Reagan of emergency medicine. But as a result, he has one of the coolest and most balanced emergency medicine careers I have ever seen.

    I got an equally important lesson in residency. Raymond Pitetti, MD, of the Children's Hospital of Pittsburgh taught me never to say no. He was referring to one of his fellows who had recently turned down a research opportunity. "When you're a fellow, you never say no!" he raged.

    I think he is right. This is a Buddhist koan of medical careers: you must be outstanding at saying no except when you cannot say no. "Keep your radio on except when you don't." Allowing the two to simultaneously coexist is critical to success in a medical career.

    The Principle 5: The Ó Coileáin Ancillary: Nobody is only a physician, although this can be forgotten in the passion of a medical career. I am also a husband, a father, a brother, and a son. I'm a rugby player, too, although not a very good one, and a banjo player (even worse). Don't neglect these identities. Marrying my wife Kelly was without a doubt the best thing I ever did, and protecting that relationship underlies everything I do. Luckily for me, Kelly is Irish by ancestry (from the Ó Coileáins) and Cajun by early upbringing — yikes! — so she has no trouble clarifying for me exactly those times when I should be implementing this ancillary. In other words, when the spouse says the radio is off, the radio is off.

    Principle 6: Remember where you came from. I learned this from an EMT-I in Pagosa Springs, CO, where I cut my teeth in EMS. I told him I was going back to school to complete my premedical courses. He grunted, grimaced, and then said, "When you're a doctor, please remember where you came from." I have always tried to honor his words.

    Needless to say, it is more difficult for some people to remember this principle than others. It helps to bear in mind principle 4 (you will fail). Remember that we are links in an overall health care system where every link is critical and more effective than all the others in its own time. When you need to cut me out of a car or pull me from a burning building, send a fire-rescue EMT, not a brain surgeon. We all need to remain humble and respectful. Also remember that in a dharmic formulation, physicians are all servants in our social order.

    Principle 7: Be here now. Be engaged with what you are doing at each stage of your medical training and practice. That holiday trauma rotation may suck at the time, but hey, what an extraordinary experience it is. Many Buddhist schools teach that enlightenment involves escape from the cyclical patterns of worldly suffering. What we often don't realize is that suffering is not our inevitable state but simply our psychophysiological response to stimuli.

    The American Buddhist nun Pema Chödrön wrote, "The aspiration to rejoice can feel feeble compared with our resentment or self-pity. We know how easy it is to let emotions hook us and shut us down." She points out that our desire for relief from suffering and the methods we use are definitely not in sync. Key to finding relief is aspiring to rejoice in, or at least appreciate, even those activities that at the time seem useless. True, as a budding urologist, you may never need to look in the eye again, but remember what David Wheeler, MD, a family practitioner in Cashiers, NC, told me after peering into the hidden depths of the retina with an ophthalmoscope: "You have just seen something that less than one percent of the human species will ever see."

    Health care providers, especially physicians, become expert at deferred gratification. If you lose the ability to revel in the stage you are in, you will lose the ability to be satisfied with the stage you reach. This cell line leads to the classic midlife crisis. By all means, plan and be willing to make sacrifices for future goals. But remember, each room you enter contains the most important patient of your life at that moment. And every moment of your medical career has something of potential significance; it may even be transformative significance. Including this moment right now. Go turn your radio on.

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