Monday, July 22, 2019

Living an Intentional Life: This is Water

by Bob Arnold (@rabob)

I am not sure what led me to go from thinking about data and evidence in the literature to waxing philosophical recently. It may be that I saw Rufus Wainwright in concert and heard him sing “Hallelujah” with his sister, Lucy Roache Wainwright (Google it). It may be that one of our cardiology fellows died suddenly of unknown reasons and everyone at my hospital is a little fragile. Or that I was just on service and trying to balance the existential realities of sadness and dying with teaching learners and dealing with institutional budget cuts. But when I sat down today and tried to think of what article to review what popped into my mind was David Foster’s Wallace’s 2005 Kenyan commencement address.

This is where I go to whenever I am feeling philosophic. I go to it because it, more than anything else I’ve ever read, summarizes the human experience, what is real about it, and what is hard about it. And so, it reminds me of how hard it is to stay present, be curious, and think about is “just in my head”. It is too long for a blog post (and I hope you’ll go here to read or watch it). So what I am going to do is give you some illustrative quotes and then a couple of comments.



There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says "Morning, boys. How's the water?" And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes "What the hell is water?"

The point of the fish story is merely that the most obvious, important realities are often the ones that are hardest to see and talk about. Stated as an English sentence, of course, this is just a banal platitude, but the fact is that in the day-to-day trenches of adult existence, banal platitudes can have a life or death importance.

Think about it: there is no experience you have had that you are not absolute center of. The world as you experience it is there in front of YOU or behind YOU, to the left or right of YOU, on YOUR TV or YOUR monitor. And so on. Other people's thoughts and feelings have to be communicated to you somehow, but your own are so immediate, urgent and real.

As I'm sure you guys know by now, it is extremely difficult to stay alert and attentive, instead of getting hypnotized by the constant monologue inside your own head (may be happening right now)….It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience. Because if you cannot exercise this kind of choice in adult life, you will be totally hosed. Think of the old cliché about quote the mind being an excellent servant but a terrible master.

If you're automatically sure that you know what reality is, and you are operating on your default setting, then you, like me, probably won't consider possibilities that aren't annoying and miserable. But if you really learn how to pay attention, then you will know there are other options. It will actually be within your power to experience a crowded, hot, slow, consumer-hell type situation as not only meaningful, but sacred, on fire with the same force that made the stars: love, fellowship, the mystical oneness of all things deep down.

Because here's something else that's weird but true: in the day-to-day trenches of adult life, there is actually no such thing as atheism. There is no such thing as not worshipping. Everybody worships. The only choice we get is what to worship.

It is about the real value of a real education, which has almost nothing to do with knowledge, and everything to do with simple awareness; awareness of what is so real and essential, so hidden in plain sight all around us, all the time, that we have to keep reminding ourselves over and over:

"This is water."

"This is water."

It is unimaginably hard to do this, to stay conscious and alive in the adult world day in and day out.


So, what does all this mean for us as palliative care clinicians (or humans)? First, I think it reminds us how easy it is to see our daily lives as normal. I love rounding with first-year medical students who are just amazed that clinicians walk in on people and have conversations with half naked people, sometimes while getting on or off the toilet. That we have difficult conversations in rooms where there is a patient next door (and the cleaning person, dietician and four other people coming in and out). It is so easy to become numb to the hospital experience that you do not realize how completely bizarre it is and how off-putting and alien the experience of health care is.

Second, the stories that I tell in my head about patients, families or other clinicians are just that - stories that I tell in my head. I need to lose my certainty about the story and gather information about the other stories in the world. I need to continually ask myself whether my reactions are because of what is going on in the world, or what is going on in my head.

Finally, I need to cut myself a break. It is really hard given that the only experiences I have are my experiences, to get caught up in that experience. So much of what was resiliency activities (like meditation) are about helping me maintain my awareness and give me choices over what I see and what I do. My days are hard and the budget cuts suck. When I get knocked off balance, realizing that this is the human condition, helps gets me up the next morning, appreciate what I have and move forward.

Next week, I go back to reviewing articles.

Robert Arnold MD is a palliative care doctor at the University of Pittsburgh and a co-founder of VitalTalk. He loves both high and low brow comedy (The Good Place and Nanette), pop culture (the National Enquirer and Pop Culture Happy hour) and music of all kinds (not opera tho!)

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