Musings of my Monkey Mind:
Explorations on Insanity
INGRATITUDE AND INDEBTEDNESS IN THE MEDICAL PROFESSION
Carmela J. Javellana, M.D.
A lot of physicians I am acquainted with, including myself, have humungous egos. I kiddingly tell my staff, who take me seriously of course, that nobody else in the practice is allowed to have an ego bigger than mine. I like being in charge, bark commands, delegate boring scutwork to someone else. I feel entitled to a regular flow of drug samples and lunch meetings, and I consider drug reps as my friends and colleagues, especially when my belly has been fed before another afternoon of problem solving and barking more commands. I get paid for my biased opinions taken by my patients as wisdom and knowledge. Those who cannot tolerate my style of psychotherapy and polypharmacy usually don’t stick around and go somewhere else, but I am smugly confident that the constant stream of miserable people will find their way to my office and worship me. I am living my dream job.
The more I ponder on this concept, the more I recognize the truth behind this: I could not be a doctor without my patients. My identity as a physician is defined by people who bring in their woes, just as my identity as a spouse cannot be realized unless I were married. Like everyone else, I have personas I draw on depending on the circumstances. At home, I am evil stepmother, wife, dishwasher, dog feeder, cat poop cleaner, among others. Another hat is Minister’s Assistant at the Salt Lake Buddhist Temple. Roles define my identity, but who am I really? Who am I without the M.D. (which largely means “major debt”) after my name? Who was I before I was born, or before I graduated from med school?
Buddhism, now my “naturalized” religion, teaches that there is no such thing as a fixed ego, no fixed self, because this self I call Me is constantly transforming and evolving. Thank goodness, because I don’t want to be stuck in 6 grade. Or so I think. Thinking isn’t knowing, but my big fat ego cannot tolerate the probability that it cannot know everything. After all, doctors are supposed to know everything. My patients come to me wanting me to fix their problems and make their misery go away. One even said I’m responsible for their feelings. I used to fall for that bullshit when I was a resident. So, if I’m in charge of someone else’s mental health, that makes me a powerful person who can lift the burden off someone else. And if I am that powerful, people should be grateful to me. They owe me. This ingratitude renders me blind to those who really make it possible for me to be here: my patients.
One way to realize this humbling Truth is through the practice of Naikan. Nai means “inner” and kan means “deep looking.” Put together, this Japanese word means self-reflection, but not just the usual Western psychotherapeutic concept of “insight.” It is the kind of deep looking that ruthlessly exposes the ego in its complete and honest nakedness under the penetrating light of Wisdom and Compassion. It is a process of self-examination without reservation, one that requires the confrontation of fear and shame with courage and humility, because holding back from Truth makes this spiritual practice lose its meaning and purpose: the cultivation of gratitude. The heart of Naikan reflection centers on the Three Questions: What have I received? What have I given? What difficulties have I caused?
When I ask these three questions relative to my patients, the answers I come up with make me realize that I am the receiver of grace, of trust, of wisdom all along. The stories, the breakthroughs, the transformation from hopelessness to empowerment that I receive on a daily basis outnumber anything I have ever given back to my patients, because anything I have given back I had to have received first: prescription paper from the printer, pens from last year’s drug reps stores of goodies, information from journal articles, personal experiences and testimonies from other physicians – all bits of kindness I have received and passed on to the next human being who walks through my door. In the meantime, I constantly interrupt my staff for more demands, cross-examine the embarrassed child this day who got in trouble at school, keep a parent outside wondering what on earth her adolescent and I are talking about, and limit the supply of benzodiazepines to a patient with full-blown panic attacks because I think I have a better idea. The summation of my development and growth as a human being in this profession can only be attributed to the other suffering human beings like myself, all ego-bound, who have taken it upon themselves to risk baring their soul to a stranger who calls herself a psychiatrist because of their inherent trust in the medical profession. I have to ask myself, who am I kidding? Who is the recipient of compassion here? At some point, the distinction between patient and physician dissolves into a non-issue, because the giver and the receiver are the same. We are all in the same toilet bowl together. This humbling realization allows for a little more humanity in an otherwise egotistical megalomaniac profession designed to serve only one purpose: service that comes from humility and gratitude.