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For the past twenty-five years I have been compelled to use everything I know from my Zen training to understand how we can best face the suffering of others

Listening to a Physician listening to Patients- a guest blog

This is a simulated encounter between a Japanese medical student and a standardized patient.

I know something of the training of physicians and I know something of the training of chaplains. They are very different forms of training. A physician relies on knowledge and experience in their work. A chaplain relies on presence and a therapeutic self. It is rare to find a chaplain or a physician who can cross over into the other realm in their work.

But the following long essay is by a physician who can and does cross over into that realm of presence and self-awareness that I write about so often as tools to enable us to face suffering. It is written by Mako Wakabayashi, a Japanese physician, a first-year resident in Internal Medicine, working in a hospital.

I first got to know her a year ago when a colleague in Japan asked if I could help her find a two-week experience, training in the United States in Family Medicine. Family Medicine has a very limited role in Japanese medicine but Mako had been exposed to its founding principles and felt that it was exactly the kind of medical care she wants to learn and provide.

Her training experience in a Family Medicine residency program in Springfield, Missouri had a profound impact on her. She found mentors as well as the freedom to explore what it means to care for someone in the way that feels closest to her deeply-held values. She especially saw and felt the significance of deeply understanding her patients because the patients’ background, ideas, and behavior influences their acceptance of their physician’s approach to treatment. As you will see below in her tales of two patients, without that acceptance a physician’s work can be frustrating and inefficient.

For both of these patients (whose names have been changed to protect their identity) you can feel her wrestling with issues of how to talk with those who suffer, or more accurately how to “be” with those who suffer. I have invited her to be a guest blogger precisely because she understands how that “being” demands the self-awareness of a chaplain. She understands that the mental and physical presence of a physician has a large impact on the quality of care provided.

I have retired from most of my professional work in training physicians, but I remain committed to aid any physician who understands how powerfully self-awareness can be of service to themselves and their patients. Hence my ongoing support for Mako Wakabayashi’s development. Now, listen to her stories. They are long, but this is a physician’s work in the trenches of health care.

Gordon Greene

Spring Green, Wisconsin


Case 1: in the outpatient clinic

My preceptor and I entered the patient’s room. The patient, Lucy, was new to us, a thin middle-aged woman with pale skin and long dry hair, swings her body back and forth as she sat, rubbing her hands.  We introduced ourselves. She threw a glance at us, saying “Hi” to the ground with her hoarse voice.

The doctor, dressed in her usual flannel shirt instead of the white coat, sat on the step of examination table with a computer on her knees, looked up at Lucy and said, “How can we help you?” Lucy looked discouraged and said, “I have pain everywhere”. We asked her to tell us more, but she didn’t say anything more than “pain,” playing with her hair.

The doctor was reviewing Lucy’s past records, yet tried her best to keep eye contacts and said, “I see. I’m reading your past record and listening at the same time. I’m sorry about that. Please continue.” Lucy said, “That’s fine”. She continued, “It’s hard to live with pain. It never goes away. I had to take care of my grandchildren. I can’t do it anymore.” in soft but somewhat appealing voice. “What’s more, I have been having hard stools, which bothers me a lot”, she added.

We let her talk, asking questions in between. She repeatedly insisted on having severe pain and anxiety. We asked about her coping methods. She said, “Meds. I ran out of them and need more.” We told her that we’ll discuss it after physical examination.

Lucy has a history of appendicitis, thyroid nodules, cervical cancer, HCV, and skin abscess. She has used IV drug in the past. She has three children. We asked her if she smokes. Lucy said “I smoke one pack a day. I know it’s bad. I’ve already started to cut down.” The doctor gently smiled, “I’m glad to hear that. That’s great.” Lucy also smiled to us, “Thanks, I know I can quit”.

We asked her about her diet. “I try to eat healthy. A lot of fruits and veggies, and of course fish and meat.” she said. Her physician smiled and said, “OK, nice”. Lucy’s face became brighter. Her voice became more confident.

After going through her history, we started her physical examination. We examined her head, cranial nerve, nose, mouth, neck and hands, listened to her heart and lungs, examined her back, had her lie down and examined her abdomen. “Any pain?” her physician asked her while pressing her abdomen. “No, not pain but weird”, she knit her brows. We had her sit up, checked sensation, power, and her reflex with hands instead of a hammer. Lucy laughed said “that’s interesting”, seeing her legs moving. We assessed her gait. Surprisingly, she didn’t report much pain throughout the examinations other than mild discomfort.

We discussed the findings in lay language, and our plans for treatment including effective diet and medication for constipation, the risk of smoking, counseling and medication for her anxiety, and appropriate pain management. She agreed to have a blood test for thyroid assessment.

We asked her, “Any questions or concerns?”. Lucy said, “Thank you for listening to me. You really listened to and understood me. I appreciate that. I understood what you said. I feel ok now.” She smiled again.


Discussion of Case 1

From what she told us, I could tell that she may never been felt heard by doctors and has never had a chance to understand what is going on. Because of this, she may have thought that her feeling would be ignored anyways before we met. She has an extensive medical history and she could have been worried that something bad is going on. No wonder she was relatively reluctant to talk with us at the beginning of our conversation.

What made Lucy shift from being stressed and discouraged to being confident and open in this short encounter? This is the kind of question that fascinates me. One answer could be that the preceptor’s flannel shirt and her low sitting position relative to Lucy eased the power gap Lucy might have felt with doctors in the past. Another could be the doctor’s non-judgmental responses which gave Lucy confidence in herself and provided reassurance that this was the safe place to talk about herself.

In comparison to this American patient encounter, in Japan there are many practices that interfere with the kind of shift we experienced with Lucy. There, any doctor would dress in a white coat or in professional clothes. There, doctors are called “sensei” which is the same word as “teacher” in Japanese, reinforcing the perception that physicians simply give patients their recommendations in the way that a teacher provides information to students. Advanced testing and complex treatments lead to the assumption for both patients and physicians that educating patients is not worth the time it would take. In Japan, I often heard patients tell their doctors “I don’t know about medicine. Nothing to do other than leave it up to you, Sensei.”  As a result, the patient may get the best treatment for their disease but not for themselves.

Then, what shifted Lucy from reporting pain at the beginning of the encounter to feeling relief by the end? Perhaps the thoroughness of the physical examinations showed respect for her report of pain “everywhere,” let her reevaluate her symptoms with us simultaneously, and helped her understand her doctor’s thinking about the causes.

Pain of course doesn’t always have a pathological basis but can also be caused by anxiety, fear, distrustful, and discouragement. When all are addressed, the pain can be diminished.



Case 2: in the hospital

Roy was a middle-aged homeless man with poorly-controlled type 1 diabetes, admitted to the hospital for “complicated ear infection”. It turned out not to be mastoiditis by the time I visited him with the resident who was assigned to his care. His record said he was recently admitted to the hospital for a similar ear infection on the same ear, got drainage, was discharged and lost to follow up.

I went to Roy’s room with the resident. He was lying on the bed with his eyes closed. He was wearing a cap and glasses. He was thin and bald and had dark-brownish rashes all over his body which seemed to be due to his insulin resistance. We introduced ourselves to him. He was nodded. The resident asked what has happened to him. He pointed to his right ear, which was swollen and red. He said, “It happened again.”

The ear auricle rotated anteriorly. As we guessed before we saw Roy, it required immediate drainage before the infection further spread and invaded the bone. The resident said, “Did you go to ear doctor after you were discharged last time?”. He said, “No,” playing with his hands. Silence. We said, “We’re going to take a look at your ear. That may cause some pain. We are sorry about that.” As we examined his ear, he was frowning a little. “Is it painful?” He nodded. The resident explained “You have a severe ear infection. We need to drain the abscess. Is that ok?” He nodded. “We will prepare and come back soon.”

We came back to Roy along with our team, meaning our attending physician, one senior resident, the junior resident who is his doctor, and me. The junior resident prepared for the drainage and said, “OK, we will make an incision to your ear and put the fluid out. The same thing you went through last time. You will feel pain. I am sorry.”

As the resident began, Roy appeared to be in a severe pain. I put my hand on his hand. I couldn’t say anything other than “You must be in a severe pain. I am sorry for that – we are here with you.” As the work proceeded I explained where are we now and how much longer it will take. He held my hand tightly, clenched his teeth, but never said a single word and never resisted. Each of us said to him, once in every 3 minutes or so, “It must be so painful. I am sorry for the pain. you’re doing a great job.”

The abscess was large. The resident packed it after she drained it as much as possible with the help of the senior resident. The attending was supervising. The resident said, “Ok, we finished. Thank you for your patience. Please take a rest for a while. We put a gauze on your ear.” Roy nodded. While the resident cleared the instruments, I talked to him, putting his things back as they were before we began.

When I asked Roy about his glasses, I realized that it is hard for him to wear due to the gauze bandage. “I think it hard for you to wear your glasses and cap right now.” I said, having no solution in my mind.  “That’s fine. I can see,” he replied. I was relieved and said “Ok, I put your glasses on this table so that you can use when you need it.” He said “Thanks.”

We asked Roy “Do you feel pain? Anything you’re worried about? Anything you need right now?”. “No thanks,” he answered. He was already about to be fall asleep. We left his room.

Our plan was to monitor Roy overnight and discharge him on the next day after the discharge consult with otolaryngologist. His infection was so severe, which wasn’t drained completely yet, and the team felt he needed to receive follow-up care with a specialist. But our job was to make sure that he would see the otolaryngologist.

Another problem we also wanted to address was Roy’s high blood sugar. It was above 250 at that time. We needed to lower it down. The resident asked me to find out about his understanding of his diabetes and its management. This was our conversation when I went in to see him:

“Hi, how are you feeling?”


“How is your ear pain?”


“I see. It will take time for the fluid to completely come out but I hope you will get better soon. Any concerns about your ear right now?”

“No, thanks.”

“I would like to ask about your diabetes. Your blood sugar is above 250 now which is high. We need to lower it down. High blood sugar is bad for your ear infection as well. OK?”


“Could you tell me more about your diabetes and how do you manage it?

“I have been having it for a long time. I use insulin.”

“I see, that must be hard. Do you check your blood sugar at home?”


“What is the normal range for you?”

“It changes. I know mine is always high compared to others but that is normal for me. I feel dizzy once it become below 160.”

“I see. How do you take insulin?”

“Before I eat. And if its high, I adjust it by myself.”

“Do you use any other type of insulin?”

“I used to, but that makes me feel dizzy. I will faint if I use it. I don’t want to use it. Not anymore.”

“Ok, any other thing you would like to share with me?”

“No…, wait, I used insulin flash but I had to change it to current regimen two years ago.”

“I see, do you know why?”

“My insurance.”

“Ok, thank you for sharing with me. I will discuss your blood sugar management with the resident.”

“Ok, thanks, good bye”.


It was hard to help Roy talk in his own words and to gain an understanding of what he was doing to manage his diabetes. It was, however, the first time he really talked. I knew that I didn’t have much time until we began management of his blood sugar but I was so happy I could finally spend some time and be able to hear him speaking more than one or two words at a time.

When I spoke to the resident, we understood Roy’s history. However, his blood sugar was too high to be left to his own management. We thought we needed to use insulin intensely to lower it down at least into a safe range. But we realized this most likely would conflict with his experience – “I know mine is always high compared to others but that is normal for me. I feel dizzy once it become below 160.”

Also, we thought we needed to start discussion on Roy’s blood sugar management in general as his base line itself was too high especially if he doesn’t have a primary care physician.  I visited him with the resident. The resident explained our thoughts. He nodded but still said he was reluctant to use long acting insulin as he will lose consciousness.

The resident replied, “I understand you feel dizzy if you use another insulin and that you don’t want to use it. Your body becomes used to high blood sugar. So, you may feel dizzy at a higher blood sugar than other people do. However, it is not good for you. We would like to lower your blood sugar to a safer number overnight, using insulin. I know you are afraid of losing your consciousness, but you are in the hospital now and we will be closely monitoring you. How does that sound to you?” He nodded assent. And she explained how we would give him the insulin. Again, Roy nodded.

The next morning, Roy’s blood sugar had decreased but not as much as we expected. We visited him again. The resident asked him “Hi. How are you feeling?”


“Did you feel dizzy yesterday?”


“Your blood sugar is still high but it decreased. If you didn’t feel dizzy, I recommend that you to adjust your home regimen.” –

“No,” he said with his strong voice, looking at the window.

“Why not?”

“I didn’t feel dizzy because I took sugar after I got that insulin.”


Roy’s answer left us without words for a while. When we explained our plan to him yesterday, he nodded, appeared to understand and agreed with the plan. But in reality he didn’t. He just acted like he was going along with our advice.

Now, the resident again explained to Roy the risk of high blood sugar and the need to lower down the threshold at which he feels dizzy by adjusting his insulin. The resident also explained that if we did it slowly, he wouldn’t feel dizzy and his body would eventually get use to the lower blood sugar. She also told him she was happy to be his primary care doctor and to do the work with him.

Roy nodded but declined the offer, saying that he had seen an endocrinologist.

After talking over Roy’s reluctance to follow our plan with our team, we decided to start afresh and ask him what he would like to take. So we visited him again.

The resident said, “We were sorry if we ignored your ideas. We would like to do our best for you. It is also true that your blood sugar needs to be lower. How much and what insulin do you think you would be able to take?” Roy tilted his head.

We gave Roy some example regimens as some options. After each one he either nodded agreement or shook his head. From this we decided what medicine to prescribe upon his discharge.

The resident said, “You will get the call from the ear doctor about follow up. Please make an appointment and see him. I know you didn’t last time but it is very important to cure it completely. Ok?” Roy sighed and said, “Ok.”

I asked Roy, “Was there any reason you couldn’t see them?” He said, “I didn’t get a call last time. I waited but nobody called me.” His face was angry rather than sad. The resident said “I am sorry about that. We will make sure that they will call you this time. But in case you don’t get a call from them again, I will give you their number. If you don’t get a call, please call them, OK?” The resident wrote down the phone number for his ear doctor. She also wrote the phone number for the hospital’s endocrinology department and said, “in case you need it”. He said, “Thank you” and smiled. He was discharged.


Discussion of Case 2

Roy initially didn’t talk much. He didn’t ask anything. He didn’t reveal much of himself. So it was hard for us to understand who he really is.  Like Lucy in the Case 1, his minimal words and eye contact told us that he had already given up being heard.

Why did that happen to Roy? One reason could be his homelessness. Being homeless narrows down the choices people can make, possibly leaving him discouraged to say what he hoped for with his medical care. A homeless person may also fear judgement because of his or her living condition, leading to more of a power gap with their physicians than others might feel. The four doctors and one med student during the procedure around him must have been too many for him.

Reflecting on the impact of homelessness, I would like to share what I heard previously from some homeless people during an externship in Los Angeles, a city where homelessness is a large issue. My intention in recounting my memory of those I met is to provide some insight of the emotional impact of homelessness.

There were numerous people without permanent homes both inside and outside the hospital in LA. They were there almost every day. Sometimes I saw the same person was in the same place. I decided to talk to each of them in the hospital. I have heard a lot about them from the doctor at that time but I wanted to hear their own words. I decided to talk to them as a medical student at that time. I asked specifically how they feel about the doctor or hospital.  Here are their voices. Each of them reflect some aspect of being homeless.

“The doctor was the last place I want to go.”

“They always judge me.”

“No doctor will believe what I am saying”

“I don’t have a house. The hospital is better than outside. It is safer and cleaner.”

“I just need antibiotics. I don’t need any advice.”

“We have so many problems you will never be able to handle.”

“I was the same person just as doctors till few years ago when I got injured and unemployed.”


As for my diabetic patient with the ear infection, another source of his distrust of the care we were offering would be Roy’s lack of support, including the fact that he didn’t have his family nearby. Having someone who connects to one deeply inside, or who understands one makes a huge difference. It would give one experience of being understood. He might not be physically alone as he should have someone living near his area, however, the problem is the fact that he was emotionally alone.

Having diabetes type 1 is a non-reversible, life-long illness, placing Roy in a difficult situation. It is well recognized in chronic illnesses that pain – from fibromyalgia for example –  an alter patients’ behavior. Indeed, the impact of chronic illness in general on emotional regulation which further related to psychological distress and affect their behavior has been suggested1. Especially in his case, the contribution of a chronic condition to this particular medical interaction cannot be ignored given that he knew his difficulties in managing his diabetes and had suffered from a fear of hypoglycemic symptoms.

Our attitude of expertise and control definitely influenced our relationship with Roy. But that attitude was something we could have changed. Even though he was reluctant to talk, we should have still waited until he opened his mind to tell us his own story before we asked so many closed questions, working to resolve what he has been felt for a long time. It was only a few times but he did say “his words” to us and there was always the opportunity to listen to him. However, we didn’t do that enough.

Now I would like to think why we didn’t. One reason was that Roy was in relatively critical medical condition. In emergency situations where immediate action is warranted to save their life, we may need to not spend time fully addressing the patient and their concerns. That is what we are supposed to do as physicians. This is why the judgement used in addressing an emergency is very important.

But, it is also important that we circle back to the patient and their needs once they become stable. We didn’t do that for this man. I think we actually sought safety and our own comfort when the time with our patient was limited. It was true that high blood sugar added to severe infection is dangerous but being in that state for few days wouldn’t kill him. We were in a rush to make sure that he would help lower his blood sugar by the time he was discharged.

On the other hand, I think the resident working with Roy did her best, based on her limited time. The resident must have felt a lot of stress as a physician, making thoughtful discussions with the patient difficult. To be honest, I also felt frustrated about this case as it sounds like there is no solution nor right answer.

In retrospect, here are some things we could have done differently even with those difficulties:

  • During the procedure, everyone should have sat down and talked to him more.
  • We could have asked him why he missed his previous follow-up appointment at earlier time during his stay.
  • After he said he doesn’t want to get more insulin, right away we should have asked what he wanted and why.
  • More importantly, we should not have rushed for an immediate solution. We wasted valuable time before we could gain his trust.
  • I have heard that some clinicians visit the places where homeless people live to gain their trust and offer some help. I believe understanding the context of a patient’s life, and offering some help so that they can come to us when they are ready someday are the best solution and make a huge difference. Opening our mind to our patient, showing compassionate and offering some help, and wait till they open their mind to us.


Reviewing these two cases, now we better know what to do. However, I have been overwhelmed with the difficulty of doing it in a clinical situation and how hard it is to wait with uncertainty. We need to always keep in mind that a patient’s feeling of being ignored is the price we pay for our sense of comfort and control. I want to be brave enough to face the patient’s needs without making my own a priority. It is better to suffer together and support each other, sometimes with coworkers and sometimes with patients. Practice this attitude again and again. Fail, reflect and try again. It will never end and it keeps making us a better physician and supporter for our patients as far as we continue practice.





1          Wierenga, K. L., Lehto, R. H. & Given, B. Emotion Regulation in Chronic Disease Populations: An Integrative Review. Res Theory Nurs Pract 31, 247-271, doi:10.1891/1541-6577.31.3.247 (2017).


Zen Training outside the Dojo

8 February 2020

I finally self-published the book I’ve been working on: once called Wrestling with Angels, now called Facing Suffering. When originally describing it, I would say that it is an account of my three months of training as a hospital chaplain. Now I’m realizing that is not what the book is about. Out of the numerous review copies I sent out to chaplains, including ones who intimately know that same training program, only one sparked a response. I’m guessing that the book must seem to have little to do with others’ experience in chaplain training.

But I also heard from people training in Zen who read a review copy. And from their insightful responses I realize that what I really wrote was about my form of Zen training, Zen training that took place in a hospital and not a Dojo. Given that, I thought it might be useful to capture here some of what I needed in order to train intensely in Zen outside of a Dojo setting.


  1. “I didn’t ask for this.” – The first necessity is a compelling question, one that cannot be answered within a dualistic perspective. And it is not a question that you simply thought up – it is one that is overwhelming in its demands. In my case, I needed to find out how to face suffering. Suffering lies at the core of Buddhism, at the core of medicine, at the core of family struggles. And those three arenas – Zen, patient care, and family – are the core of my life.
  1. “I own this place.” – The second necessity is the place where you can face that question. Those grounds can be anywhere but I use that word “own” deliberately. By that I mean that you feel that everything within that environment is yours to use as a tool for training. Nothing is off limits. In my case, it was a community hospital, full of patients, staff, technology…and suffering.
  1. “Don’t give up!” – You need a commitment not to quit until the question is resoundingly answered. If it is a compelling question, it won’t crack easily. You’ll find yourself in some dark places with no way out. In my chaplain training, I needed help to remain committed. I hit one of those dark places – a place where I felt that I was injuring a fellow chaplain – and turned in my letter of resignation. Fortunately, it was rejected.
  1. “No!” – So that’s another thing you need in order to train outside a Zen dojo: someone to say “no” repeatedly. In most contemporary learning environments, it seems like the teacher’s job is to nurture, guide, offer reinforcement. But for those of you who do koan training, contrast that with your Zen teacher’s refusal to accept your most heartfelt answer when he or she knows that it is not genuine. In my chaplain training, I had a supervisor who likewise had the radar to know what was genuine and what was not. There were a lot of “no’s” in my conversations with him. As a result, I had to push deeper and deeper, working to get beyond what was genuine.
  1. “Take away every habit since the day you were born.” – The fifth necessity is a willingness and an ability to take yourself apart. By that I mean that you challenge everything about yourself that you think is true. Whoever you think you are going into your training, you are willing for that all to fall apart. Most likely you are not as strong, as smart, as kind, as sensitive, as friendly, as accomplished, as anything, as you think you are. The world doesn’t work the way you think it does. People don’t behave the way you think they behave. Things don’t get done the way you think they get done. As a result, you find yourself on a life raft with very few things left: in my case, my breath and my sense of gravity.
  1. “Keep throwing yourself against that brick wall.” – If you accept #5 as a necessity, you are going to make mistakes as “you” is taken apart. There has to be a willingness to accept that there is no taking apart without there also being mistakes. It is not a neat or pretty process. If you accept that, then you have no problem with picking yourself up off the ground after one failure, knowing that another failure is just around the corner.


I’m now rereading what I just wrote – not pretty stuff. Not the way in which Zen training is usually portrayed in America. Are those six elements necessary for any student training in Zen? I can’t say. I do know that I needed them for my training with Tanouye Roshi and I needed them to learn how to face suffering.

If you are interested in reading Facing Suffering, send an email to If you wait a few months, you can also order it from any bookstore or online sources, both in paperback and e-book format.

Blog #5

Aug 9, 2018

One reason I like mowing the meadow is the fresh smell every few seconds as different plants are sliced while the tractor chugs along. There is a news stream to the nostrils that I can’t decipher but I love to receive it anyway. What the plants are expressing is important, and maybe of even greater significance than what I read in the actual morning news, but I don’t understand them.

It’s not fair to say “of greater significance,” but it is hard to read that written morning news because there too I find myself saying I don’t understand. How is this day’s story possible? Without understanding it is easy to go numb. Easy to just live here in the woods day by day.

One of the recurring themes I use when teaching physicians is learning how to face suffering. But it is one thing to face suffering of the sort that seems to just be part of our lives – the loss of an aged father – but it is far more difficult for me when the suffering is seemingly caused by someone’s cruelty, ignorance, hatred, or greed. Those are the difficult stories.

I’ve been struggling with that second form of suffering, wanting to understand, wanting to speak, but not wanting to just add to the noise of the moment. But I was thinking of the late Japanese Zen Master Omori Sogen this morning, the teacher of my Zen teacher. And I was thinking of the physical character of his life – recognizing that everything seemed to align. How he breathed, how he walked, how he wrote, how he taught. Everything seemed to just line up, no loose edges. People who met him said every encounter left them with a clean feeling, nothing muddy.

Those who know of his training in the old sword school that includes the form or kata we call “Hojo” would say of course that is how he was. His physical training in swordsmanship was so severe that not only did “straightforwardness” (jikishin in Japanese) go into his bones but into his life. My teacher, Tanouye Roshi, lived the same way. Who he was in the morning was the same as who he was in the evening.

The older I get, the more I understand how incredibly difficult that last step is. Every step, every word, every breath, every encounter feeling like it is just one thing. Without shugyo (intense physical/ emotional/ spiritual training) early in life, it is very difficult to do the necessary shugyo later in life that leads to this straightforwardness.

I think I landed on this quality in Omori Sogen’s character this morning because I realized that is what I long for in every politician, every businessman, every teacher, every police officer, every physician who has a large impact on the lives of others. “Longing for” by itself is an empty phrase but I had to get all of these things I’m describing to the surface before I could look at my own alignment, my own straightforwardness. That’s yet one more step along the way…

Blog #4

June 13, 2018

Here’s a strange bit of suffering, something of my own. It feels vague, ill-formed, self-indulgent, but also real. Something I often tell medical students when talking about suffering is that I try not to judge degrees of suffering – “this suffering is much more significant than that suffering.” We first have to really feel it before you take that kind of comparison anywhere. Point being, I’m giving those instructions to myself right now.

I’m embarrassed to write the following sentence but I will. I’m suffering from a loss of what I felt was the American Dream. Or at least the American Dream as it was for a white, middle-class boy born in 1950 in small town Illinois. Certainly this feeling has been amplified by our current political landscape but it was brought to a fine point while watching the 2016 documentary about Noam Chomsky called “Requiem for the American Dream.” Nail by nail, plank by plank, he builds a framework for understanding the changes that occurred following the 1950s and 1960s, the era he calls “the golden age of the American dream.”

For Chomsky, the tale is told in terms of what has happened to wealth, power, and democracy since the 1970s. For me the more personal story is the question of what happened to our ability to think about the needs of others. I was a naïve fringe participant in the Vietnam protests of the late 1960s – lots to ridicule in what some writer once called something like the sound of thousands of small children banging their spoons on their highchair feeding tables – but my memory of the outrage back then was a sense of why should we be killing so many people for reasons that don’t make sense. We had lived through those elementary school drills of ducking under our desks if a nuclear bomb was dropped nearby but I don’t recall any particular fear of Communism. Stopping the spread of Communism by decimating the land and people of Vietnam made no sense. So stop.

My point is that the outrage was personal – abstractions about world order were given more weight than questions about how we take care of the needs of others.

I was a bit too young for involvement in the Civil Rights movement, but there was that 1968 takeover of my college’s administration building. And long talks with the college chaplain, a man who had been imprisoned with Martin Luther King when King wrote “A Letter from a Birmingham Jail.” All of the injustices of the past hundreds of years – emotional, political, social, economic, educational – made no sense to me. Given a chance to start to correct them, why wouldn’t we?

This makes me think of the new museum in Montgomery, Alabama – the one that pays homage to the thousands of people lynched since the Civil War. I can’t quite imagine stepping into the pain that museum captures, but I feel that I must. How can I not say “I was part of this?” I have some of this cruelty within my DNA. We have only a few family stories about Quaker ancestors participating in the Underground Railroad. But those are noble stories so of course they are remembered. But there must have been men in my lineage who watched one of those lynchings, or saw the body afterwards, or heard the news, and then did nothing.

The Civil Rights movement was meant to begin our healing from all of this, but I don’t see much of this these fifty years later. There are enough like me that we helped elect a Black president, and watched his family set example after example of forebearance, but what of all that now? It feels like we watched a movie about such a fantasy and then all went home.

News cycle after news cycle, there is somebody new that we don’t want to help take care of. Puerto Rico still suffering after the hurricane – who cares?

The Weight of Suffering

24 April 2018

I’ve just finished participating in a day-long symposium on Suffering and Caring: Perspectives from Medicine, Philosophy, and Zen, held at the University of San Francisco. I was the Zen representative, working with two philosophers and a physician and an audience primarily of USF students. Over the course of preparing for the symposium, the meaning of some core words played an increasingly interesting role in the discussion. With this blog, I want to discuss how those meanings sounded to me as a Zen teacher and chaplain.

Gravity and Grief

Two of the contributions were made by Geoff Ashton, a philosophy professor at USF. He first told me of the direct linguistic relationship between “gravity” and “grief,” both of them stemming from “gravis,” a Latin word for “heavy.” And it makes sense that they are related. For example, we have the phrase “with a heavy heart” as one way to express sadness. The phrase now is mostly used in a metaphorical sense but we would have once been more familiar with grief as a visceral sensation of weight in the body.

I know this because I was with my mother when she died and I can still feel the sensations of just sitting silently at her bedside for the thirty minutes before my sister arrived in the room. I felt drained of all thought. Every part of me sagged, felt pulled toward the floor. Draining and sagging are gravity at work. Gravity and grief as one.

We will circle back to the role of gravity in learning to face suffering, but for the moment I want to flag gravity’s core significance in our style of Zen training. The focus of the work of zazen (Zen meditation) is learning to lengthen one’s exhalations. In order for that to happen, numerous muscles throughout the body need to “wake up” and to relax. For muscle tissue to wake up, it needs to feel the pull of gravity.

That process of feeling the work of gravity throughout the body takes a great deal of time because of the ways in which we identify with our habits. For the most part we are not aware that the ways we hold our body in the gravitational field is all based on neuromuscular habit. This means that literally we don’t feel gravity in the majority of the muscles in our bodies. At least we don’t feel that gravity until we are struck by grief, or we train intensely in Zen.

Suffering – the Sanskrit roots

The second contribution from Geoff was a new look at the meaning of “duhkha,” the Sanskrit word usually translated as “suffering” and a core concept in all forms of Buddhism. One common derivation of the original meaning of duhkha is “having a bad axle hole.” This refers to the effect of an off-center hole in one of the wheels that holds the axle for a two-wheeled cart. As you might imagine, if you were in that cart you would have an uncomfortable ride. You would suffer.

But Geoff, as a Buddhist scholar with significant learning in Sanskrit, pointed to another derivation of the meaning of “duhkha.” The Sanskrit dictionary compiled by the Oxford scholar Monier Monier-Williams, states that the word “duhkha” was originally formed from “dus,” meaning “bad,” and “stha,” meaning “to stand.” Thus, a root meaning of duhkha can be expressed as “bad posture,” with the resulting discomfort being the visceral basis for suffering.

Suffering – the Latin roots

The final core word that was discussed during the symposium was again this “suffering.” For Tom Cavanaugh, also a philosophy professor at USF, the significance of suffering lies in its Latin roots. The two parts are the Latin “sub,” meaning “under,” and “ferre,” meaning “to carry” or “to bear.” His translation becomes “be under what one carries.” For example, one can carry a heavy bucket of sand in your hand but one would not be “under” that load. You would not be suffering in the sense that the Latin root words present. But place that same bucket on your head or your shoulder and now you are under that load.

His illustration for this derivation of “suffering” is an early painting by Vincent van Gogh called “Miners’ Wives, Carrying Sacks of Coal.” The women are bent over by their loads, some of them almost bent over ninety degrees, as they trudge through the snow. For Tom, this is what one form of suffering looks like. You bear something – physical, emotional, spiritual – and you walk on.

It strikes me, however, that there are people who are “under what they carry” but without any appearance of suffering. For example, imagine a sailor home from the sea, leaving his ship with his heavy seabag on his shoulder and a smile on his face. Or one of the women who have learned to carry a heavy load – a basket of fruit or a vase full of water – balanced on her head, walking with grace over a long distance. Why does such a sailor, such a woman, not personify suffering?

The answer clearly lies clearly in how the weight of that load is being transferred through their bodies to the ground. One can of course let their body sag under the weight, but there is also the opportunity to somehow redirect that weight, to push up, push skyward. Paradoxically perhaps, this seems to lighten the load, most likely because the body comes into better alignment and more of the weight passes through to the ground without being “held” by muscles in-between.

We seem to have some kind of instinct for this pushing up. I first noticed it in my training in zazen (Zen meditation) as I worked endlessly with my breath and posture to find the “right” position. Finally it came to me that if I directed my exhalation down – not literally breathing toward the ground but feeling the sensation of exhaling going down through my torso and abdomen – my back, neck and head seemed to naturally straighten and push toward the ceiling. It felt like working a hydraulic car jack. The jack takes the downward pressure of your hand on the lever and transfers it into the upward pressure needed to raise the car. As a result, the zazen seemed to come alive.

Learning to Face Suffering

To go back to the meaning of duhkha – bad posture – notice how that suffering can benefit any of us if we use that weight to teach us the breath and the posture needed to carry that weight with less suffering. Another paradox then: suffering helps us to end suffering.

This phenomenon – this standing up against the weight of suffering is significant to me for two reasons. One reason is the one just mentioned about learning a more effective form of zazen. As you learn to push up from the hips, through the back and the neck, with the crown of the head then pushing toward the ceiling, your senses become more open and your exhalations become longer. If you instead simply sit there like a rock – all gravity and no countering lift – your thoughts rather than your breath will dominate the experience and your zazen never comes alive.

The second reason is a more public one. For many people whose work is to alleviate the suffering of others – whether physical, emotional, or spiritual – one of the toughest skills is to learn how to face that suffering without it becoming a burden of your own. For example, you might be someone who works to ease the suffering of a woman not unlike the miner’s wife that van Gogh painted. If you become bent over with the weight of her burden – coal or sadness – then all of my experience as a hospital chaplain suggests that you won’t be of much help to her.

Instead, whatever words might be spoken with that woman, I would want to also be showing her what’s possible in her own body. I can show her what it means to let the weight of that load – physical, emotional, spiritual – flow through me as efficiently as possible. Just enough use of muscle and bone to hold that weight, but no more than necessary. And a use of breath that drives the countering lift.

The gravity of grief is countered by the lift. The suffering of bad posture is countered by good posture. And the suffering of being under what you carry has been transformed into a form of grace. Suffering has been faced.

Given a choice between Heaven and Hell…

I got a phone call from a long-time Zen student, one who knows how to cut to the chase in most conversations. He asked, “Does suffering end?”

Without thought, I answered, “No.” We then got into the story of his suffering and I explained more of my “no.”

But later I was reflecting on why that “no” came so easily. In most descriptions of Buddhism in America, one usually finds something along the lines of “It’s a religion focused on finding the end to suffering by living according to certain principles.” That’s a straightforward contradiction of what I told my student.

Introductions to Buddhism usually outline one of the core teachings of the Buddha – the Four Noble Truths. In English at least, these Truths are usually presented in sentence form, expressing something like:

  1. The first truth is the existence of suffering for all humans.
  2. The second truth is that suffering is caused by ignorance of the true nature of existence.
  3. The third truth is that suffering ends when you understand the nature of existence.
  4. The fourth truth is that the there is a method to ending suffering called the “Eightfold Path.”

In my own lineage of Zen, we would say that expressing these things in this manner doesn’t cut to the core of suffering. We would say these things more simply and we would not call them “truths” because that implies something to believe. For a Zen person, these things only have meaning once experienced, and experienced in your bones. We might say:

  1. To be alive is to experience suffering.
  2. The experience of suffering occurs because we are attached. Attached to ideas, to things, to illusions and delusions, to people, to a sense of who and what we are.
  3. To become detached from any of those does not lead to an end of suffering. Rather it is transcending the duality of attachment/ detachment that leads to an end of suffering.
  4. The method of transcending duality is through severe mind-body training.

Coming back to my student, what would it have meant if I answered his painful question with a “yes”? For one thing, I would have reinforced a duality – the sense in which he could end suffering without ending himself. Another duality I would have reinforced is that it would be possible for him to not suffer while those around him are suffering. I don’t understand how that would be possible – how can my well-being be separate from that of other people? Hence my “no” to a Zen student.

That’s where I get the title for this entry. In my lineage of Zen, the traditional instruction for a priest is, “Given a choice between Heaven and Hell, go straight to Hell.”

Now, I also work at times as a hospital chaplain and can easily imagine a patient asking me the same question, “Does suffering end”? It would be heartless in that context to say “no.” What do they care about duality? But that doesn’t mean I would easily say, “Yes, it does.” More often than not, I ask them to tell me about this suffering. I’m listening for the story of this suffering. And sometimes, given the right conditions, the suffering starts to ease. Not because any of the objective causes of the pain have ended but because I have now stepped into the suffering with them and they are no longer alone.

When Breath Becomes Air

I saw a man in the intensive care unit last night, close to brain death. Tubes and monitors all around. The hospitalist on duty is carefully explaining to the family of this forty-three-year-old man the sequence of events likely to take place over the next several hours as his skull continues to fill with blood following a fall earlier in the day. The blood at some point will put so much pressure on his brain stem that too many of the brain cells that support his breath and heartbeat will die. Determining the point of death in such circumstances seems to be an imprecise art as the patient is tested for the presence of several key reflexes. The final check, however, seems to be the delivery of pure oxygen into his lungs as the ventilator is shut off. By testing his blood in the minutes that follow, it is possible to see if his body is doing anything useful with that oxygen. If not, he is said to be dead and the ventilator is restarted in order to keep his organs in the condition needed if they are to be “harvested” for possible transplant.

All said carefully with care and compassion to the family. But I’m watching them trying to figure out when in this progression of events their brother, nephew, son actually dies.

Here’s what is filling me as I watch and listen. Go back a few years ago. It’s early evening and the rooms and corridors of my mother’s nursing home are still and quiet. Mother is dying, her hospice nurse earlier saying, “maybe tonight, maybe tomorrow.” I’m alone with her, singing what I can remember of “Swing Low, Sweet Chariot.” I’ve been counting her breaths ever since arriving at her bedside that morning. My brother-in-law calls to ask how she is doing. To give him some form of a quantifiable answer I say, “I’ll count her breaths for you. There’s one…” I wait. There are no more. Her nurse comes in, listens to her heart and chest and says, “I’m sorry.” It’s 8:45 pm. And she is dead. I say goodbye to my brother-in-law, not quite absorbing that her death would be so distinct. This said by a hospital chaplain who has watched many dozens of last breaths.

I’m alone now, still hearing the sound of her last breath, coming as it did from far off down the arroyo she knew so well in Santa Fe and then sweeping onward, up the slopes of the Pecos Mountains to the east. A breath of air that never really had a beginning or an ending, just a puff that filled her for the moment and then was gone. Death was clear and certain. Clear in a way that was not to be available to that family in the ICU that night.

(with thanks to Paul Kalanithi for the title phrase)

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