The Cup is Full. Surgery, Koans, and Self-Awareness.

Excerpt from The Wisdom of the Knife. Zen in the Art of Surgery

The more you know, the less you understand - lao tzu

    ... Surgeons always start their careers with someone else’s style. That’s understandable. You have to start somewhere. It’s moronic to reinvent the wheel, and you don’t want to make unnecessary mistakes. If you watch enough surgery you’ll recognize certain styles and schools of training like you see in the martial arts. There’s tradition, pride, and a whole lot of ego involved. Some surgeons take the style they’ve trained with and add to it, improving on it, finding new efficiencies, incorporat­ing advances in instrumentation and tech­nology. Others depend only on what they once learned. That’s who you don’t want to be. The surgeon incapable of exceeding his style grows old, literally. He is incap­able of seeing a fundamental truism in surgery – that the law of imper­manence pervades everything, surgery and all else. Sur­gery evolves, it advances, and only the surgeon who is beyond a system can explore that truth and evolve sur­gically. It benefits him. It benefits his patients. The sur­geon who is really serious about his art has no fixed style at all – he operates only in what is, what the mo­ment and patient in front of him call for. The evolution of surgical technique has through the ages notoriously been resisted by the establishment and the insecure sur­geon. What it reveals is a deeper in­se­curity, an unwill­ingness to accept that the only constant in life and sur­gery is change, impermanence. Resisting change, reject­ing the new, firmly sticking to a creed, all provide the lesser surgeon with the illusion of stability, because that is all he is comfortable with.

    People have a tendency to believe they are right and the things they have and do are better. That’s called self-serving bias. It’s human nature, and there’s an evolu­tion­ary prerogative for it. Confident individuals gener­ally do well in the world, and self-serving bias often accom­panies the confident. It happens a lot in the opera­ting room. Surgeons accept the credit when everything goes well and are quick to blame something or someone else when things go wrong. It works wonders for one’s self-confidence, but it doesn't help make for a better surgeon. Self-serving bias causes surgeons to overestimate their skills, and that can get them in to trouble.

    To counteract self-serving bias, you need to be able to step back and look at your work objectively, to “medi­tate” on outcomes, what went wrong and what went right. It helps to discuss results with colleagues and to be exposed to new or different techniques that expand upon what you comfortably know. It helps to be hum­ble. If you can learn to understand yourself, without having things register at an emotional level, you can dis­cover your limitations. Knowing what you don’t know actually opens up your mind so that you can learn something new and give up something old. You can de­cide to expand your skill set or understand that there may be a better surgical option, and it’s okay if you’re not the one who can provide it. 

    A koan is a story that teaches you a deeper truth about life. There’s one in particular I like to tell my residents. The way the koan is traditionally told, the student comes to the master’s temple to inquire about Zen over a cup of tea, but I substitute surgery for Zen, my resi­dent for the student, coffee for tea, and the surgeon’s lounge for the temple. The attending surgeon is the Zen master - no substitution needed there. This version of the story takes place in the surgeon’s lounge between surgical cases at the all too familiar, but still terrible, coffee pot. It’s been a long mor­ning, an even longer turnover, and all the surgeon really wants is a quiet cup of coffee, but he’s prompted to go over the next surgical case by his read-too-much, overly eager resident. This resident doesn’t just have questions, he has “ideas.” Instead of listening, he expec­torates one idea after another about how the case should be done. The surgeon listens patiently and begins to pour coffee. He pours the young surgeon’s cup full, and then keeps on pouring. The resi­dent watches until he can hold back no longer, “Stop! The cup is full. No more will go in!” to which he replies, “Yes, and like this cup, you too are full of your own opinions. How can I teach you surgery unless you first empty your cup?”

    I’m being just a little facetious here as residents are expected to have read up on cases ahead of time, have ideas and a surgical plan, and it’s all in the fun of teaching and learning surgery. But it’s not uncommon that the surgeon who has left training and is comfortably ensconced in practice finds himself with a cup that’s no longer empty. In surgery, to empty your cup means to get rid of your self-delusions so that you can look at the art, and maybe life too, from a truly new perspective. This takes a great degree of self-awareness and effort. You have to analyze your­self, know what your style is, understand your prefer­ences and habits, your strengths and weaknesses, your conceits and fears, how your experiences reinforce or limit your options in surgery. You have to know the limits of your ego. It’s only then that you can go beyond your style and what you know, to see the new, the un­known, the unconventional. That’s where you’ll find truth, and that’s when you evolve as a surgeon.  In a way, you must die to all that you know and that is un­comfortable because it confronts that model of security we so happily delude ourselves with so that a better surgeon can emerge from within us. In Zen, it’s called beginner’s mind, one that has no preferences or desires, one that sees things without bias, as if for the first time.

    Do you take the time at the end of a case or the oper­ating room day to reflect on your experiences? To see what you might have done differently? Or is that not your habit at all? And thereby every case you finish has no meaning beyond its completion. Is that how you ap­proach your life as well? Self-examination leads to self-awareness, and self-awareness leads to self-improve­ment.

    We are all defined by what we have experienced and learned. It’s how we see the world around us, and what we see reinforces what we know. And for so many of us there isn’t any room for something new. Look at the world differently. It all starts with examining our self – our experiences, habits, insecurities, delu­sions, and what we don’t see because our minds are full. Becoming a better surgeon starts and ends with you. You, alone, are the path.