Dr. Craig Blinderman looks at his own grasping, anger, and delusion and uses the principles of contemplative medicine to become a better caregiver.
As the Covid-19 pandemic puts enormous pressure on health care systems in the U.S. and globally, often overwhelming local systems, all of us in the medical field have been forced to take a hard look at how we care for our patients, our colleagues, and ourselves.
We are asking ourselves, how do we find the capacity to endure? How do we mitigate moral distress and compassion fatigue? How do we prevent burnout? How do we respond to stressful encounters with patients and their families?
How do we as health care providers work with the three poisons in our clinical practice?
As a student of Zen, I approach these questions through my practice. I come back to my breath, to my vows, and to the wisdom of the Buddha’s teachings. My practice shows up for me in every patient encounter.
Let’s take an example from a few weeks ago. I was seeing one of my elderly patients and her two adult daughters in my palliative care outpatient clinic. Helen is a seventy-five-year-old woman with a rare neurodegenerative condition. It has cost her the ability to walk, swallow food, and even speak in full sentences.
Her daughters help with her day-to-day care, as the patient lives alone and can barely perform any activities on her own. She needs assistance with standing, repositioning herself, toileting, bathing, and transfers from bed to chair. She also has a twenty-four-hour home attendant who helps with some of these tasks, as well as food preparation, cleaning her apartment, and other household tasks.
After the appointment, I received an email from her daughters asking me to fill out some paperwork to help change her home attendant services to two twelve-hour shifts, with the understanding that this would result in more active care at night. They explained that her neurologist had been unsuccessful in trying to change this and asked if I could write a letter to document her need for this change.
I explained that I had never written such a letter and wasn’t sure I was the best qualified to make this argument to her insurance company. As the emails went back and forth, I felt myself becoming irritated, annoyed, insulted, and even angry at how they were treating me and my desire to be of service. I felt like they were taking advantage of me.
I did write the letter but felt unsettled by the interaction. I knew that such feelings would only grow and become a source of distress to me in this therapeutic relationship, possibly even interfering with my ability to care for my patient. The encounter added to my stress and impacted how I thought about myself and my role as their doctor.
When I viewed this through my Zen practice, I could see that the thoughts and feelings coming up for me in this clinical encounter were examples of what Buddhism calls the three poisons—grasping, anger, and delusion.
The first poison of grasping (or greed) was about my wanting recognition for my efforts. My narrative of being “the good doctor” was partially driving my desire to please this family, even though it was outside of what I would normally do with respect to patient care. I was feeling greedy; I wanted more praise. I wanted to feel like I was the doctor who would go above and beyond for his patients. So I would take on this additional role in her care, trying to do what her other physicians were unable or unwilling to do, even if I really didn’t want to.
The second poison, anger (or resentment), was the dominant emotion for me whenever this request came up, and in other interactions with this family. There was the time they called on a weekend, when I was not on call and it was not an emergency, and they made other requests as well that many of my colleagues would categorize as inappropriate. So, the question was, how would I work with my anger and resentment and still provide good care?
The third poison is ignorance, in this case the delusion of separateness. After finishing the clinical encounter with this patient and her family, I thought to myself, “I am not going through this, they are.” In this simple thought I began to delude myself that I was separate from them, and separate from all beings.
This was the ignorance of my small mind. When I separate myself like that, I break my vows. The very first of the ten grave precepts, as understood by the Zen Peacemaker Order, is “Recognizing that I am not separate from all that is. This is the precept of non-killing.”
Whenever I create separation from others—when I think about myself and my needs over theirs, when I am not present in my words and actions, when I see others as somehow different than myself—I am breaking my vow of not killing.
So how do we as health care providers work with the three poisons in our clinical practice? How do we not become exhausted, emotionally depleted, frustrated, and angry in such situations? How do we prevent the caregiving work from overwhelming us, leading to compassion fatigue and burnout? How indeed do any of us do that in our work?
A simple practice, for me, is to take a pause.
This is something we have been teaching in our new Contemplative Medicine Fellowship, which is part of the work being done at the New York Zen Center for Contemplative Care, where I am a member.
To take a pause is to let whatever is happening simply be. To notice what is coming up in each moment, as it is. When I breathe deep into my hara, my lower abdomen, I can allow the greed, anger, and delusion to mix into my body, almost like mixing ingredients in a cauldron. The effect this has is to empty my mind and open my heart.
Over time, I have noticed that this practice has allowed me to become more aware of how I get caught in old stories and narratives. I can see how emotions lead to thoughts that separate me from those I am providing care to. That separate me from myself.
Ease and joy come when I can catch myself grasping at these habitual and conditioned aspects of my mind. Then I come back to my breath. I come back to my vows. I come back to my true nature. I come back to my calling as a doctor to serve others.