The Alphabet of the Heart
Mississippi, 2003
Everything is beautiful at a distance. After returning to medicine, I could look back at my life in Newport Beach and see the beauty in every mistake, every wrong turn, and every misguided belief about what mattered most. The first thing that I had told Ruth I wanted in 1968 was to be a doctor, and after watching all my money and most of my friends disappear, I knew that being a doctor was my most powerful magic.
I was not sure exactly how to proceed following the dot-com crash or whether I wanted to continue in the role I had at Stanford as a clinical professor of neurosurgery. My interest in entrepreneurial activities was at its lowest then. I had in the past served as a consultant to hospitals that had difficulty providing neurosurgical coverage or were interested in developing neuroscience centers of excellence. I wanted there to be the best neurosurgical care possible, especially in areas where the majority of the population lived in poverty.
One day, out of the blue I was asked to advise a public hospital in southern Mississippi. As it was an hour from New Orleans, a city I loved and where I had gone to medical school, and it was a free trip, I said yes. The hospital was the primary provider of indigent care in the area, and as happens often many doctors didn’t want to provide such care, as the reimbursement is very low. In addition, in this case, a private hospital run by a large hospital chain was incentivizing many of the specialists to practice at their institution, thus further exacerbating the situation. The problem was not only a lack of adequate neurosurgical coverage but a lack of coverage in the areas of neurology, orthopedics, and stroke care as well. I assessed the situation and explained to the hospital administration that there was a problem with the way they were making offers to potential doctors. They needed to explain that these doctors had the opportunity to be part of the development of a regional center of excellence. Not just to appeal to their egos but to that part of them that was present when they first became doctors . . . the ability to make a difference.
To create this regional center would require a large sum of money. Following the presentation, the board unanimously voted to fund the vision to create a neuroscience regional referral center if I would agree to be the director of the program. It was an opportunity to lead an effort that would have a major impact in a place that really needed it. I surveyed colleagues and friends, none of whom could understand why I would voluntarily leave the weather of Northern California and the vibrant intellectual community of a major academic center. But after multiple visits to Mississippi, meeting wonderful people, and seeing a real need, I decided to make the move. In a fairly short period of time, I was able to recruit an extraordinary set of colleagues who enthusiastically engaged in the development of the center.
Many people in the United States don’t appreciate that on almost all measures of quality or efficacy of healthcare, their country is in the last quadrant while having the most expensive care of all industrialized (first-world) countries and the least satisfied patients. What is also not appreciated is that every other industrialized country in the world offers universal healthcare to all of its citizens with better outcomes and much lower costs.
It has been shown that childhood poverty has a profound effect on one’s health and ultimately future. Of course, I was well aware of this from firsthand experience, but when I moved to Mississippi this reality was again brought home to me. I remember being on call in the emergency room and seeing a child who had had a seizure and was now unresponsive, requiring a tube to be inserted into his windpipe to allow him to breathe. An emergency brain scan had been performed showing a large mass in his right temporal lobe compressing the normal structures of the brain and the brainstem. I spoke to the child’s parents, who told me that he had been suffering for some time from an ear infection. Because they did not have insurance, the child was being seen by a nurse practitioner at a free clinic. He had repeatedly gone back because the antibiotics he had been given were not working, and he continued to complain of worsening ear pain and ultimately of a massive headache. They had no money to see a physician. The child had become confused and disoriented the day before, and they thought it was due to his fever. His parents finally took him to the emergency room after the seizure. To get there they had to call a neighbor to drive them since they didn’t have a car.
I walked into the exam room and saw this beautiful child with a breathing tube on a ventilator. His frightened parents were at his bedside. I introduced myself and quickly examined the child, who had a widely dilated pupil on the right, and a slightly dilated pupil on the left. He was unresponsive, and his exam was consistent with pending brain death. I informed the parents that I had to act immediately to save the child’s life and I asked them to leave the room. The scan had shown a mass that extended from the region of the right mastoid, that part of the skull that contains the ear canal, into the temporal lobe. With the child’s history it was apparent that this child, whose ear infection should have easily been treated, had developed an infection of the mastoid bone that extended into the brain, resulting in a brain abscess. Such brain abscesses are rarely seen in this day and age. I quickly prepped and draped the child, clipped the hair over the temporal region, anesthetized the skin, incised the scalp, and drilled a burr hole overlying the area of the abscess. I then inserted a needle, and as I aspirated, pus filled the syringe. So much pus that I had to change the syringe three times.
I then took the child to the operating room, but it was too late. He was brain-dead. I left the operating room and walked into the waiting room. The parents stood. I could tell by how they looked that they were used to disappointment. I informed them that I had done everything I knew how to do to save their child’s life and was not able to do so and that he was brain-dead—his body now only being kept alive by machines. After their tears and grief, they thanked me for trying, and my heart broke for all the times in their life people had not cared enough to try.
An ear infection or lack of health insurance should never cause a child’s death.
Almost two years later, Hurricane Katrina struck. For many who had the ability to leave, it was an easy decision. Yet many more were stuck, stuck in a place of huge devastation, where recovery would take years if not decades. I struggled trying to decide whether I should leave or stay after the storm was over. I had come to assist the community, and I was enjoying caring for patients who truly needed help. We were building a resource for the community that would last into the future.
By this time, I had remarried a wonderful woman I had met shortly before giving my Accuray stock away. We had a young son, and my wife found it very difficult to live with my long hours and the daily reminders of devastation from Hurricane Katrina. Ultimately, we decided that she should move back to California with our child permanently, and I would remain in Mississippi but travel back and forth to California every six to eight weeks for a visit.
Many colleagues and friends couldn’t understand why I just didn’t leave permanently with my wife. The reality was that while that would have been easy, I couldn’t face all those in the community, many of whom were now close friends and had believed in the vision that I had offered for that hospital becoming a regional referral center. For two more years I stayed and for several years after I remained deeply involved in this center, which became the center of excellence that I had envisioned so many years before. I finally left having built something that was, in fact, bigger than myself. After losing my wealth, I was committed to helping others, and this center, serving the needs of the poor, felt in a way like atonement for the years I had spent pursuing wealth and power.
As I was contemplating returning to California, I realized I very much wanted to go back to Stanford. I also had been wondering what it was about Ruth’s teachings that seemed so compelling and realized that at their core they were about opening the heart. Acting kindly and compassionately with intent. One of my fascinations was to understand how the brain and heart worked and interacted. Could compassion, kindness, and caring have signatures in the brain?
When I returned to Stanford on the neurosurgery faculty, I began meeting with colleagues in psychology and neuroscience to discuss what work was being done in this area. It turned out that there were a small number of researchers who were doing groundbreaking work on how being compassionate, altruistic, and kind affected the reward centers in the brain and positively affected their peripheral physiology. Compassion and kindness, it turned out, was good for your health. This research became my top priority, and I recommitted to the skills Ruth had taught me but developed them to better reflect the lessons I had learned. My notebook had been destroyed in Hurricane Katrina, when our house flooded, but I constantly replayed my conversations with Ruth in my head, hoping to gain new understanding, decades after the fact, about what Ruth had taught me. I immersed myself in the research that now was proving scientifically the benefit of all that Ruth had taught me. I wanted to study what it meant to open the heart and to understand why Ruth had emphasized this as being the most important. Just as I had made a list of my goals so many years before, I made another list of ten. A list of the ten things that open the heart.
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.