Into the Magic Shop Read online

  I sat with it. I read it over and over, and then I suddenly saw it as a mnemonic, CDEFGHIJKL. It was a way to remember each aspect of what I had learned. The alphabet of the heart. While I continued the components of the meditation practice that I was taught in the back of the magic shop so many years before, I began a new practice each morning of reciting this new alphabet. After relaxing my body and calming my mind, I would recite this alphabet and set one quality from the list of ten as my intention for the day. I said them in my head over and over again. I found that it centered me, not only as a physician but also as a human being. It allowed me to start my day with a powerful intention.

  THE ALPHABET OF THE HEART

  C: Compassion is the recognition of the suffering of another with a desire to alleviate that suffering. Yet to be compassionate to another, you must be compassionate to yourself. Many people beat themselves up by being hypercritical, not allowing themselves to enjoy the same kindness that they would offer to others. And until one is truly kind to oneself, giving love and kindness to others is often impossible.

  D: Dignity is something innate in every person. It deserves to be acknowledged and recognized. So often we make judgments about someone because of how they look, or talk, or behave. And many times such judgments are negative and wrong. We have to look at another person and think, “They are just like me. They want what I want—to be happy.” When we look at others and see ourselves, we want to connect and help.

  E: Equanimity is to have an evenness of temperament even during difficult times. Equanimity is for the good times and the bad times because even during good times there is a tendency to try to maintain or hold that feeling of elation. But trying to hold on to the good distracts us from being present in the moment just as trying to flee from the bad does. Grasping at that feeling of elation is not realistic, not possible, and only leads to disappointment. All such ups and downs are transient. Keeping an evenness of temperament allows for clarity of mind and intention.

  F: Forgiveness is one of the greatest gifts one can give to another. It is also one of the greatest gifts we can give to ourselves. Many have used the analogy that holding anger or hostility against another you feel has wronged you is like drinking poison and hoping it kills the other person. It doesn’t work. It poisons you. It poisons your interactions with others. It poisons your outlook on the world. Ultimately, it makes you the prisoner in a jail where you hold the key yet won’t unlock the door. The reality is that each of us in our lives has wronged others. We are frail, fragile beings who at various times in our lives have not lived up to our ideal and have injured or hurt another.

  G: Gratitude is the recognition of the blessing that your life is—even with all its pain and suffering. It takes little effort to see how so many in the world are suffering and in pain. People whose circumstances allow little hope of a better life. Too often, especially in Western society, we look at each other and feel jealous or envious. Simply taking a few moments to have gratitude has a huge effect on your mental attitude. . . . You suddenly recognize how blessed you are.

  H: Humility is an attribute that for many is hard to practice. We have pride about who we are or what we have accomplished. We want to tell and show others how important we are. How much better we are than someone else. The reality is that such feelings are actually a statement of our own insecurity. We are searching for acknowledgment of worth outside of ourselves. Yet doing so separates us from others. It’s like being put in solitary confinement, and it’s a lonely place to be. It is only when we recognize that, like us, every person has positive and negative attributes, and only when we look at one another as equals, that we can truly connect. It is that connection of common humanity that frees us to open our heart and care unconditionally. To look at another as an equal.

  I: Integrity requires intention. It requires defining those values that are most important to you. It means consistently practicing those values in regard to your interaction with others. Our values can easily disintegrate, and the disintegration can at first be imperceptible. If we compromise our integrity once, it becomes that much easier to do it again. Few start out with such intent. Be vigilant and diligent.

  J: Justice is a recognition that within each of us there lives a desire to see that right be done. It is easier when we have resources and privilege to have justice. Yet, we need to guard justice for the weak and the vulnerable. It is our responsibility to seek justice for the vulnerable, to care for the weak, to give to the poor. That is what defines our society and our humanity and gives meaning to one’s life.

  K: Kindness is a concern for others and is often thought of as the active component of compassion. A desire to see others cared for with no desire for personal benefit or recognition. The extraordinary thing is that research is now finding that your act of kindness not only benefits those who receive your kindness but benefits you as well. The act of kindness ripples out and makes it more likely that your friends and those around you will be kinder. It is a social contagion that puts our society right. And ultimately kindness returns back to us, in the good feelings it generates and in how others treat us . . . with kindness.

  L: Love when given freely changes everyone and everything. It is love that contains all virtues. It is love that heals all wounds. Ultimately, it is not our technology or our medicine but our love that heals. And it is love that holds our humanity.

  • • •

  THIS MNEMONIC connects me to my heart and allows it to open. It allows me to begin each day with intention and purpose. And throughout the day, when I am stressed or feel vulnerable, it centers me in the place I wish to be. It is the language of my intention. It is the language of the heart.

  If Ruth were here, I think she might discover that I had finally learned to open my heart. And that has made all the difference.

  • • •

  THE HEART BEATS a hundred thousand times a day, sending two thousand gallons of blood through an intricate system of blood vessels that if stretched end to end would cover sixty thousand miles—more than twice the circumference of the earth. The ancient Egyptians believed that the heart—the ib—survived death, and in the afterlife, it passed judgment on the human who possessed it. The ancient Egyptian word for happiness is awt-ib, literally meaning “wideness of heart.” The word for unhappiness was ab-ib, which meant “a truncated or alienated heart.” In many cultures, both ancient and modern, the heart is seen as the seat of the soul and the secret place where the spirit dwells. When we read a story of a lost child, our heart can ache. When love ends, our heart can feel as if it might break and sometimes does. When we feel rejected, ashamed, or forgotten, our heart can feel tight and constricted, as if it were closing in on itself and getting smaller. But under pressure, whether from intense love or intense suffering, our heart can crack wide-open and never, ever be the same again. This is true not only in a metaphorical sense but in reality. In fact, there is actually a condition called broken heart syndrome.

  It wasn’t losing my money that cracked my heart wide-open—I found liberation in losing the wealth I had sought for so long—it was the pressure of keeping my heart closed for so long that finally caused it to break open. Ruth had said, “What you think you want is not always what’s best.” I had been chasing the wrong thing, and a heart ignored for too long will always make itself heard.

  I also remembered my promise to Ruth: Someday I would teach this magic to others. I wasn’t sure exactly how that would happen, but this was the focus of my visualization practice every night. Sometimes I saw myself in my white coat embracing a patient or a family member who was suffering, other times it was on a stage, and at other times I imagined myself talking to great philosophers and spiritual leaders. Even though I was, and am, an atheist, I thought often of my experience with Ruth and my experience after my car accident and found that I could have an open mind, be dogma-free, and still know that there is more to this life than I can explain. In many ways
this was her gift as well. An acceptance that I don’t need an absolute answer.

  I feel that each of us is connected; when I look at another, I see myself. I see my weaknesses, my failings, and my fragility. I see the power of the human spirit, and the power of the universe. I know in my deepest being that it is love that is the glue that binds each of us. The Dalai Lama once said, “My religion is kindness,” and that has become my religion as well.

  I had always cared about others, and as a physician I care deeply for my patients. But the practice of opening one’s heart with intention can cause pain. Pain so intense that at times it’s almost unbearable. At times the pain didn’t allow me always to be there or be as present as I wished. But when I truly open my heart as Ruth taught me, it actually changes how I respond to the pain. I did not need to run from it; I needed to be with it. And it was the being with it that allowed me to connect with myself and truly connect with others. My relationships with my patients have changed. I make more time to listen, and I try to open my heart to each one of them. I listen to their symptoms, and then I listen to their hearts—not with a stethoscope, but with my own heart.

  • • •

  THE STETHOSCOPE was invented because in 1816 a French physician was too embarrassed to put his ear up to a female patient’s chest to listen to her heart and lungs (as was the norm at the time) and instead rolled twenty-four sheets of paper into a cone to create some distance between them. I think this distance between physician and patient has only grown larger over time. I learned that just by listening to my patients, just by giving them my time and attention and focus, they felt better. I let each of them tell his or her story, and then I acknowledged my patients’ struggles, their accomplishments, and their suffering. And in many cases, this relieved their pain more than any medication I could offer and at times even more than my surgery. Even today, I tell my students and those residents I teach that while neurosurgery requires an immense amount of technology and sophisticated equipment, my greatest success as a neurosurgeon is the result of caring with an open heart and being present with my patients.

  Another remarkable change was that everywhere I went, I saw people who were just like me. The clerk at the grocery store. The janitor who cleaned up the hospital late at night. The woman who stood at the traffic light holding a sign for money. The guy who was driving too fast in his Ferrari. And each of them had a backstory, just like me. Each of them was walking a path. Each of them struggled and suffered at times. From the person with the least to the person with the most, they were just like me.

  I had begun to let go of the story that had defined my life. I had made an identity out of my poverty, and as long as I carried that identity with me, no matter how much wealth I accumulated, I would always be living in poverty. In my daily practice I opened my heart to my mother and father, and I found forgiveness for them. I opened my heart to the boy I used to be, and I found compassion. I opened my heart to all of the mistakes I had made and all the ways I had foolishly tried to prove my worth in the world, and I found humility. And in doing so, I knew that I wasn’t the only one in the world to have been hungry. I wasn’t the only one in the world who had ever been frightened. I wasn’t the only one who had known loneliness or felt isolated and different. I opened up my heart and found that my heart had the ability to connect with every other heart it met.

  It was exhausting and beautiful and strange.

  All at the same time.

  TWELVE

  Manifesting Compassion

  I have always enjoyed opera, although I can’t say for sure why. Even without understanding a single word I often cry. Perhaps it is the raw emotion, the courageous display of passionate feeling that surpasses language. Opera isn’t something you can intellectualize or explore with the mind—it can be felt only with the heart. Most surgeons play music in the operating room—it can calm and soothe the patient or focus and energize the surgical team. Studies have shown that when music is played to patients before surgery they exhibit less anxiety and require less pain medication and sedation. Like meditation techniques, music reduces heart rate, decreases stress, and lowers blood pressure. This calming effect happens not only for the patient but for the surgeon as well.

  For me, if I play music during surgery the volume is low and the music is usually classical and calming during the critical phases of the surgery. As I am closing I might turn the volume up and play rock classics. But one type of music that I never play is opera. When I’m operating, I’m like a machine. My patients may want empathy and emotional connection before surgery, but during surgery, they want my skill, technical ability, and critical decision making. They don’t want me crying over them on the operating table. They want me to care, but not if it gets in the way of saving their life.

  June was one of my first patients in my new medical practice after I left my position as a neurosurgeon in the army, and June lived for opera. When she first swept into my office, she exuded vibrant energy and a warm spirit. She liked to wear high heels, and told me early on that she didn’t care how great a doctor I was, she was never going to give up her two greatest passions, singing and pasta, even if I told her it would save her life.

  June was a soprano in a traveling operatic troupe, and opera was both her vocation and the love of her life. We spent time during every appointment talking about her favorites—Aida, the Strauss operettas, and Carmen. Our appointments often lasted longer than usual because I enjoyed hearing her stories of singing around the country. She loved to make people feel.

  “It sounds crazy, but I love it when my singing makes people cry—that’s when I know I’m touching them. That’s when I know I’ve connected.”

  June was having severe migraine headaches, and while the neurologist had been able to treat her headaches with medication, he couldn’t fix the large aneurysm that was sitting adjacent to the left insula and that part of the brain associated with movement of the face region in her dominant hemisphere. It had been found as part of her medical workup for headache, and while it wasn’t the cause of her headache, it had the potential not only to take from her what she valued so greatly but to kill her as well.

  “Whatever’s wrong with me,” she said, “I don’t want to do anything that will injure my voice or ability to sing—it’s the most important thing I have.”

  I had to break the news to June.

  The aneurysm, based on its size of over a centimeter in diameter, needed to be dealt with promptly, and I explained this to her over a number of appointments. I felt urgency but knew that June needed to have the delicate procedure explained to her slowly over and over again. I encouraged her to consult with other neurosurgeons, including colleagues who were much more experienced, even though I had done this surgery many times. Unfortunately, some neurosurgeons even with the most serious of conditions simply, and in a matter-of-fact fashion, describe the treatment and its associated risks without understanding that while routine for us, this treatment is often the most important event in the life of the patient and their family. The two other neurosurgeons she saw in second opinion were like this. She came back scared—with a sense that she was not a person but a diagnosis.

  June needed this processing time, even more than most, and I tried to give her all the time that her condition allowed. Even back when I was a new physician, I knew that spending time with a patient was part of the art of medicine. Ultimately, we are dealing with real people who have real concerns and fears. Patients are not malfunctioning bits of machinery, and surgeons are not mechanics.

  The more I talked to June, the more I saw her anxiety dissipate. She needed to tell her story, and she needed to know that I heard her story and knew her as a person. We developed a friendship. Ultimately, she told me I was the only one she trusted to do her surgery. While it is wonderful for a patient to have great confidence in your ability, it is different when a patient is a friend. The day before her surgery, she gave me a recordin
g of her singing her favorite arias. That night I sat in my study with my eyes closed listening to her sing.

  On the morning of June’s surgery, I chose to play classic rock music from my childhood. She smiled at me warmly when she was wheeled in the operating room on a gurney and she heard the words of “All You Need Is Love” played through the speakers and they were the last words she heard as she drifted off to sleep. We transferred her from the gurney to the operating room table after she had been anesthetized, and I took the head clamp with its sharp pins and attached it to her head to secure it during the surgery. I could feel the pins penetrating her scalp and engaging the skull. I turned her head to the right and slightly extended her neck. I knew her appearance was very important to her and so I removed as little hair as possible. I reviewed the angiogram outlining the large bubble on the artery supplying a large part of the left side of her brain. It was an aneurysm arising at the bifurcation of the middle cerebral artery. I incised the scalp and turned the flap to reveal the skull. Normally the skull protects us, but in this case it was in the way. I used a craniotome to open her skull, which I then removed and placed carefully in a sterile towel. I could see her dura, that fibrous tissue that covers the brain, and knew that right beneath it was the aneurysm, keeping tune with the pulsating beat of her heart.

  If it ruptured she could have a stroke and lose her voice or she could die.

  I slowly opened the dura, and as I did, I could see the dome of the aneurysm poking out between the frontal and temporal lobes in the Sylvian fissure. I began the real work—bringing the microscope into position and using a micro-knife to dissect the delicate membrane from the brain surface, which allowed me to open the Sylvian fissure and gain access to the neck of the aneurysm, where the clip would be applied. I needed to separate it from her normal circulation. As I exposed the aneurysm, I saw that the wall was paper-thin. I could see, through the high-intensity light of the microscope, the blood swirling within the bulging and pulsating wall. It could have spontaneously ruptured at any moment. And part of the wall and neck were markedly attached to the surrounding brain, making them much harder to separate without rupture. Slowly, ever so slowly, I continued the dissection and was able to create a small path between the adherent scar tissue and the neck to allow me to place the clip. I didn’t have even a millimeter of extra room. If I erred, it would rupture. My mistake could take away the one thing that meant the most to her—singing. I turned and reviewed the various clips, and placed one on the clip applier and turned toward that pulsating aneurysm that could kill her. I suddenly saw June’s face in my mind and thought of her singing. I could hear her melodic voice. And then I thought of her paralyzed, unable to speak or sing. My hand holding the clip started shaking. Not a slight tremor but shaking. I couldn’t proceed.