Opinion

A PIECE OF MY Do You Dare to Dharma?

Alexandra E. Hedberg, This past January, in my third year of psychiatry resi- vious to me that it’s less about going crazy and more
MD dency, I found myself in a rehabbed farmhouse fidget- about realizing that you already are. I worked as hard as
Department of ing gracelessly on a veritable tower of cushions. I was anyone to do nine hours of meditation a day, but pa-
Psychiatry,
one day deep into a ten-day silent Vipassana medita- tience and persistence aside, I found that my thoughts
Northwestern Feinberg
School of Medicine, tion retreat. I was acutely aware of back pain I’d never were deafening, indefatigable, and reminiscent of a de-
Chicago, Illinois. felt before, of joint creaking I’d never heard before. Fifty ranged car radio on scan. The loudest and most asser-
other adults from all walks of life were perched around tive station was my mind’s editorialist, who spent hours
me, each of us on a spectrum from stirring to squirm- aggressively narrating my thoughts and feelings. It’s the
ing. For nine hours we had been practicing breath aware- voice that babbles when my surgeon fiancé comes home
ness meditation, harnessing gentle attention to the sen- after a busy day; it’s the voice that declares itself in
sation of breath on the nostrils. The caterwauling of therapy, leading my therapist to remark more than once
geese in the winter freeze mingled with the sounds from on my tone of “detached bemusement.” Equally men-
the modest television at the front of the meditation hall. acing was the voice of my insatiable internal wedding
This was our nightly discourse, during which we watched planner. And the voice that specialized in catastrophic
the 1991 teachings of the late S. N. Goenka, a master anxiety. “What if I lose my ability to speak after ten days?
Vipassana teacher. What if that pregnant woman has an obstetric emer-
Goenka spoke with a grin, jovially acknowledging gency and I’m the only doctor here?” Most alarming was
that each of us was contemplating the ways we might the voice that, without solicitation, interjected damn-
run away from what was surely a horrible mistake. ing judgments into my simplest observations. One lonely
“This is normal,” he confided. Our distress after the first night, as I was sitting outside by the frigid lake, watch-
day of sitting was merely the well-ingrained pattern of ing unbelievably as geese plunged their heads into the
our agitated, restless minds. He taught us dharma, the black water, my mind was loud and clear in its unmistak-
tools by which we were to finesse the art of living. Re- able declaration, “Desolate as s***.”
minding us that that we were not on vacation, he said As the days passed, however, the radio stations lost
our suffering would lessen only with hard work, only with service one by one. Thoughts became bounded by fewer
patience and persistence. Speaking in parable and hy- words and by more imagery. Nights were comman-
perbole, he likened the ten-day retreat to a “deep op- deered by vivid, riveting dreams that spared no corner
eration of the mind” and imbued us with “strong deter- of my life. Daytime equanimity became less about ac-
mination” to “work exactly as we are asked to work … to cepting torrents of back pain and more about accept-
make best use of the time, the opportunity, the tech- ing torrents of intense emotions, memories and fanta-
nique, to enjoy real peace, real harmony, real happi- sies, reckonings and reconciliations with versions of
ness.” His words had both a lightness and a gravity; his myself I have long considered archaic remnants of my
smile was balanced in part by the stern and silent coun- past. I inhabited a world without coping skills, a 30-year-
tenance of his wife, sitting at his side like an enlight- old woman reduced to a child without my practiced
ened henchwoman. panoply of distractions—without cooking, reading,
Goenka, a successful but harried Burmese business- browsing, exercising, chatting, listening, knitting. With-
man, sought out Vipassana meditation after experienc- out anything at all … but meditation, that is. I could look
ing years of intractable migraines. Vipassana translates directly into the recesses of my mind and panic, or I could
to “insight” and is the practice of honing conscious- choose to ground myself in my body’s own sensations
ness, perception, and equanimity by observing sensa- and find that, like everything else in life, the storminess
tions on the body, moving from surface to depth.1 A ma- arises and just as easily it passes away.
jor cornerstone of this technique is the observation and The passage of time felt as predictable as an
acceptance of anicca, the natural law of the universe, “the Escherian stairwell. Most hours elapsed in excruciating
inherent transience of every sensation.” After one re- torpidity, but there were moments of flow during medi-
treat, Goenka’s migraines remitted. After 14 retreats, he tation after which I would ogle the clock in disbelief at
became a teacher of Vipassana and slowly began to open the disappearance of an entire afternoon. Each day con-
meditation centers around the world, funded entirely by cluded with Goenka’s solemn countdowns: “The eighth
students who have experienced the benefits of prac- day has ended. Only two days left to work.” And just
Corresponding tice and have donated money to extend the same op- like that, the end of the retreat arrived with the same lack
Author: Alexandra E. portunity to others. of fanfare with which it began. Shy all of a sudden in front
Hedberg, MD When I decided to follow the path of a trusted friend of women with whom I’d coexisted for ten days, I broke
(aerhedberg@gmail
and sign up for a retreat, the chorus from family mem- my “noble silence” with sheepish hellos over last cups of
.com).
bers, friends, colleagues, and supervisors was singular tea in the cafeteria.
Section Editor:
Roxanne K. Young, and emphatic. “Ten days of silence? I could never do that. On my return, people asked eagerly, “Would you do
Associate Senior Editor. I would go crazy.” Three days in, it became patently ob- it again?” Harrowing and hellish as it was at times, I find

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myself feeling lighter, less encumbered, less entitled, more gra- and a decreased sense of personal accomplishment). The sequelae
cious. I am meditating 40 minutes a day (Goenka recommends an of burnout on individual physicians include depression, anxiety, and
hour twice daily). I am happily eating simpler, healthier meals. Silence suicide—residents and fellows are among those most at risk.6-8 The
is unusually alluring to me. And my take on the wind, snow, and burden of widespread physician burnout on our publicly floundering
bother of the Chicago commute has shifted dramatically—it’s as- health care system speaks to a sort of public health crisis. It necessi-
tounding how much effort it takes to rage against the weather ev- tates a large-scale “call to action,” which “includes establishing an or-
ery day for half of the year. ganizational culture and learning environment” to meaningfully cul-
Most important, the experience upended my notions of how to tivate trainee wellness.9 In a landmark gesture, earlier this year the
be a good physician. I find myself sitting with my patients’ helpless- Accreditation Council of Graduate Medical Education prioritized
ness, fearfulness, anger, and hopelessness without the familiar creep- trainee wellness at its annual education conference.
ing anxiety to do something, fix something, prescribe something. I am Though the effectiveness of meditation on mitigating physi-
humbler in supervision; I am kinder on call. When I practice giving of cian burnout is well documented, I suspect that turning physicians
myself fully without expectation of return, I find that there is no such into regular meditators will be a hard sell. The studies looking at the
thing as a thankless job. When I work to accept impermanence as resi- effects of meditation on physicians typically involve an experien-
dency’s only constant, I find that there is no utility in self-righteous tial and longitudinal curriculum. It can be challenging to incorpo-
indignation when faced with its particular challenges. rate this kind of training into residency curricula, especially when time
During my retreat, feeling vulnerable, raw, and a bit helpless, I is short and service demands are seemingly all-encompassing.
marveled at how split off is this frame of mind from my carefully Didactic curriculum is insufficient to the task. As Goenka teaches,
cultivated psychiatrist persona. I began to realize that my choice there is a substantial difference between perusing a menu and en-
of psychiatry as a career may be due to a subtle but trenchant joying a meal—moreover, “continuity of practice is the secret of
defense. Might I undo my own suffering by being the one who success.”1 Developing the most effective and feasible format in which
ministers to others? After all, suffering is what patients do, not to teach meditative practice to residents is an important task that
what physicians do. Meditation dismantled this fantasy. My mind merits further scholarly consideration.
left untended is unruly, agitated, and primitive without regard to While changes to the external training environment in resi-
my years of training, my intellectual proclivities, or my investment dency are imperative, we must challenge ourselves to facilitate
in therapy. changes within our trainees’ internal training environments. The prac-
While personally revelatory, this emotional growth would be tice of meditation is frustrating. It is at odds with our well-honed skill
unsurprising to meditation researchers. Medical literature is sets of multitasking and compartmentalizing. To overcome these ob-
increasingly publishing quality evidence on the salubrious benefits stacles, programs need to investigate ways of valuing resident re-
meditation confers on patients and physicians alike.2-4 Physician silience alongside resident productivity, of appraising meaning-
meditators are better able to “listen attentively to patients’ dis- making on par with the other core competencies of training.
tress, recognize their own errors, refine their technical skills, make As physicians, we know the value of earnest introspection
evidence-based decisions and clarify their values so they can act and reflection. To engender a shift in the culture of academics,
with compassion, technical competence, presence and insight.”3 we must start first within ourselves. Goenka teaches, “Dharma is
A study examining medical trainees found that they enjoyed to be seen for oneself … see it for yourself, try it yourself, don’t
“improved immunologic functioning, increased spirituality and accept it blindly.”1 The only way to begin is to grab a cushion and
empathy, greater use of positive coping skills and enhanced ability join the ranks of creaking knees and keening backs. Work dili-
to resolve conflicts.”5 gently; work patiently and persistently. Return your attention to
This research is happening thanks in part to a growing recogni- the bare breath, just as it is, not as you want it to be. Take refuge
tion of physician burnout (emotional exhaustion, depersonalization, in the mere breath … as it comes in … as it goes out.1

Conflict of Interest Disclosures: The author has communication with burnout, empathy, and population. Acad Med. 2014;89(3):443-451.
completed and submitted the IMCJE Form for the attitudes among primary care physicians. JAMA. doi:10.1097/acm.0000000000000134
Disclosure of Potential Conflicts of Interest and 2009;302(12):1284-1293. doi:10.1001/jama.2009 8. Schernhammer ES, Colditz GA. Suicide rates
none were reported. .1384 among physicians: a quantitative and gender
1. Goenka SN. The discourse summaries. Vipassana 5. Shapiro SL, Shapiro DE, Schwartz GE. Stress assessment (meta-analysis). Am J Psychiatry.
Research Institute. http://www.vridhamma.org management in medical education: a review of the 2004;161(12):2295-2302. doi:10.1176/appi.ajp.161.12
/The-Discourse-Summaries. Published 2010. literature. Acad Med. 2000;75(7):748-759. .2295
Accessed February 2016. doi:10.1097/00001888-200007000-00023 9. Dyrbye LN, Shanafelt TD. Commentary: medical
2. Epstein RM, Krasner MS. Physician resilience: 6. Center C, Davis M, Detre T, et al. Confronting student distress: a call to action. Acad Med. 2011;86
what it means, why it matters, and how to promote depression and suicide in physicians: a consensus (7):801-803. doi:10.1097/acm.0b013e31821da481
it. Acad Med. 2013;88(3):301-303. doi:10.1097 statement. JAMA. 2003;289(23):3161-3166. 10. Goenka SN. The necessity to practice right
/acm.0b013e318280cff0 doi:10.1001/jama.289.23.3161 concentration. Vipassana Newsletter. http://www
3. Epstein RM. Mindful practice. JAMA. 1999;282(9): 7. Dyrbye LN, West CP, Satele D, et al. Burnout .vridhamma.org/en2014-05. Published May 2014.
833-839. doi:10.1001/jama.282.9.833 among U.S. medical students, residents, and early Accessed February 2016.
4. Krasner MS, Epstein RM, Beckman H, et al. career physicians relative to the general U.S.
Association of an educational program in mindful

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