Seeking Refuge

The stream is cold, brisk, and my hands are bright pink, nearly numb when I lift them from the water. What began as a game when I was a child in a bathtub has persisted over the years: If I can cup my palms just so, and press my outstretched fingers together, maybe the water will stay. I manage, for a minute or two, to keep it from seeping out, but each time it inevitably finds its way through the spaces I cannot close no matter how forcefully I push together the sides of my palms. I empty my hands, wipe them on my jacket, and continue walking, my steps punctuated by the crunch of brown leaves. It is autumn in Point Reyes. Life is falling to the ground. Wind whistles through the canopy above me. Bushes lining the trail tremble with the arrival and departure of quails. I arrive at a lookout and admire the way the land sprawls in every direction.

It is the opposite of the world of the hospital, where I have spent most of my days since entering medical school fifteen years ago. Hospitals are places of necessary constraint. Living within the structure of hierarchy and specific boundaries confers a certain comfort. Within those walls, I know who I am, what is expected of me, my responsibilities to those I train and those I treat. Yet my work as a palliative care doctor sometimes felt like performance—service to patients offered under the steady scrutiny of others. Patients and families sat before me during meetings, my medical students and residents on either side. The unspoken rules were clear: Do not flinch at strong emotion, do not absorb what you cannot fix, do not reveal the cost of remaining calm in a room full of unraveling. I followed the rules until I could barely feel anything for anyone.

I keep walking through the woods, trying not to think about a man I’d cared for the week before, a man so breathless from lung cancer that his face turned gray and his lips were blue. He took my hand, begged me for mercy, whispering let me go. His wife and daughter shook their heads and told me that he didn’t know what he was saying. Of course he wanted to live, of course we should place him on a breathing machine. I tried to tell them that he was dying of his incurable cancer, that a ventilator may only prolong his death; instead, I could ease his suffering with medicines to treat his breathlessness, pain, and anxiety.

These types of discussions form the core of my work in palliative care. I often talk with people and their families about what therapies are most likely to support—or detract from—the quality of life they value when they are mortally ill. But this was an emergency, and my colleague in the ICU thought it safest to intubate him as discussions with his family continued. He was on the ventilator for three days, requiring more and more support, until the machine had no more support to give. Over the phone, his wife sobbed and told me that she couldn’t come in only to see him like this. He died in the late afternoon next to a picture of Jesus his family left on his bedside table. My medical student and resident were shaken. I bought them coffee and listened to their dismay over a family letting a person die alone: Why didn’t his family listen to him? Why didn’t they come in? What kind of love was that?

Though his life and death were singular, I had encountered many similar situations in my eleven years of practice; I grew steadily weary of the permutations of loss I witnessed. I’d end my days feeling as though I were in an MRI machine, the walls of the hospital closing in on me. I walked to my car with a new impulse to remove a necktie I wasn’t wearing, trying to loosen something that didn’t exist.

One morning, I stood in the hospital lobby, unable to take the elevator to my office. I thought about walking out, taking the day off. But I wasn’t interested in temporary escape. I was looking for refuge.

I hadn’t always needed refuge. For most of my life, hospitals had been my second home. When I was a child, my mother, an anesthesiologist, took my brother and me to the hospital with her on school holidays. We often sat, restless, in her office, but sometimes she would take us with her when she saw patients in the postanesthesia care unit. She asked them if they were nauseated or in pain, and I could sense from their responses, even when I was 8 years old, the singularity of her attentiveness and concern. Sometimes her patients smiled at us and asked if we wanted to do what our mother did. And despite the way antiseptic fumes burned my eyes, despite the canisters of urine and the pink basins filled with vomit, I knew that I wanted to be just like her.

During much of my training, hospitals remained thrilling: Within these walls, my teachers taught me the myriad ways the body fails us but also how to diagnose, treat, and even reverse the destruction of disease. The wards became my world, places alternately terrifying and wondrous, where I knew my place and my charge. Imperceptibly at the time, my life began to narrow, my budding profession all-consuming. I rarely called home. I stopped reading novels, delayed plans with friends outside of medicine. I forgot to pray. I became synonymous with my ambition. My calling became my life.

Those were years of necessary velocity. It was both expected and easier to remain in motion, adrenaline fueling days on call and studying at night. My classmates and I talked about the ambient emptiness we’d experience during vacations or weekends off. Outside the hospital, I filled my schedule with workouts, studying, and mindless movie marathons to avoid the swarm of feelings and thoughts best kept at bay.

But later in my residency, this strategy began to fail. I spent one month covering the ICU, wrapping myself in a blanket while typing my notes during chilly nights on call. I sipped coffee and remained vigilant outside the rooms of the sickest patients. I had always considered the ICU symbolic of medicine’s technical prowess, a place offering the possibility of dramatic rescue. But lately, the ICU had come to feel less like a place of purpose and more like a place where I absorbed the pain of others: patients, families, other doctors, nurses. I’d return home feeling unusually heavy, as though I were swollen with the grief that wasn’t mine.

During that month, I began to take short breaks outside the hospital. I observed a row of trees rising from a surrounding hill, bent from years of facing strong winds. I’d quickly return to work not just out of obligation but because velocity felt safer. One morning, after a thirty-hour shift, instead of taking the bus home right away, I lingered on a small patio, trying to forget the howls of one patient’s mother. She shook her dead son’s body, begging him to wake up. I smoked a cigarette and looked at the hills across the bay in Marin, ash gathering at my feet.

One afternoon during my palliative care training, I stood in a crowded temple watching Buddhist monks sweep away the mandala they had created over several weeks. Stunned, I began to cry as I watched them fill small bags with the multicolored sand arranged in precise patterns. Embrace the rule of impermanence, one of the monks said, adding that life is no different from the creation and destruction of the mandala. My parents had taught me the same lesson throughout my childhood: Change is the only certainty in life, and resistance to this truth is the root of suffering. But when one of the monks handed me a plastic bag filled with sand, I understood the gravity of this lesson in a new way. This physical representation of impermanence taught me that I must learn to ease my patients’ suffering while also accepting that I could not change the fact that they were dying. I tried to view death as a teacher, learning how to hold my patients’ despair without seeking to eliminate it.

Through the practice of refuge, I have come to see that I am no different from the moon or a beetle or the vastness of the sky.

A mentor suggested that I help patients to develop a relationship to impermanence. Gingerly at first, I began to talk with people about what it means to live well amid change and uncertainty, perhaps the biggest challenge of living with a serious illness. Nature offered the most striking examples of what endures and what dissolves: We talked about suffering as passing clouds of varied shapes and textures, floating through a sky that never changed. Amid unexpected storms and spells of drought alike, there were always the certain poles of sunrise and moonrise. Could these examples guide us as we consider what to hold and what to release? Could we come to see that sorrow is just as ephemeral as joy? These were among the most moving conversations I had at work, though at some point these concepts became more a part of my practice than my life. What had buoyed me through my palliative care training became an offering to everyone else.

My body seemed to understand this before my mind did, leading me outside for reasons I couldn’t quite comprehend. I had never been an outdoorsy person. I didn’t grow up camping or hiking, fearful of mountain lions or getting lost or injured on a trail. But the longer I spent in hospitals, the stronger my longing to be alone in quiet, unrestrained places. This began quite simply: At first, I took my dog on longer walks, noticing for the first time the newly planted violet succulents in the concrete median on my street. About a mile away, I came across a large park with a baseball field, its grass a meld of green and brown. A flock of geese flew above me. My mind was quiet. I looked down at my dog and understood that this would be the one time in my life that I would experience this particular moment with him. I knelt and took his face in my hands, holding him close, sharing his breath.

Sometimes I sat on a stretch of rocky shoreline along the Pacific or on a park bench admiring the view of mountains in the distance on a clear day. Sometimes I stood in a corridor of trees bordering the hospital, Japanese maples living alongside evergreens. No matter where I was, I felt myself expanding, opening in all directions, because that is what the land and the birds and the trees did. My resistance to stillness softened. I began to feel again: a deeper compassion for my patients and their families, exhaustion from tending to the emotions of everyone around me, regret over the years I’d spent thinking that I was worth only what I could accomplish, forgiveness for my inability to understand that earlier.

I hiked and I strolled and I sat and I entered and left the elevators in the hospital. At times I continued to feel the walls closing in. When I felt as though I were wearing a necktie, I asked my body to remember the spaciousness of the rocky shore, or the lift in my chest when I watched the waves. The walls began to stay put. Stillness tempered velocity. I offered no resistance.

I once cared for a man in his 20s dying of colon cancer. He was so nauseated that he could barely move. I’d tried every medication I could to ease his nausea, to no avail. His wife told me that she knew her husband was dying, that she wanted to take him home. Through tears, she asked me what hospice could offer. I answered her questions, including one about how long I thought her husband had to live. I think time is short, I said softly and slowly, giving her time to absorb what I was saying. We may be looking at days to weeks. She thanked me, blotted her eyes, and asked me if her mascara was running. It would give away the fact that she’d been crying, and she didn’t want her husband to worry.

About half an hour later, the young man’s oncologist approached me at the nursing station and raised his voice. How dare you suggest hospice to my patient, he screamed. Who are you to say that they should give up?

I could barely breathe. Nurses and students turned to watch the scene. Shock gave way to anger, but my words stuck in my throat. How dare you yell at me? All I did was answer questions! I wanted to say. Who do you think YOU are? I willed myself not to cry, then turned around and walked away. He screamed at me to come back. I went into the bathroom and splashed water on my face. I ran warm water over my trembling hands, trying, out of habit, to hold the water in my palms. I had no time to go outside; I had four more patients to see. I tried again and again to trap the water, to keep at least this one thing still in my hands.

I recently walked through North Vancouver, surrounded by trees burning burgundy and gold against a gray sky. The sidewalk was strewn with yellow and red and green leaves, slick with rain, scattered like jewels. Over the prior month, the necktie felt tighter than ever. Young patients had died of cancer, a student had taken a day off to cope with the emotional heft of the work, I’d returned home feeling like I’d failed everyone around me. I walked up a hill, passing pharmacies and salons and coffeehouses, heading toward a grove of maples outside an apartment building. I stood beneath them, their leaves glowing as though they were on fire. The sidewalks were empty. Cars whizzed by.

I first experienced a real autumn when I lived in Connecticut during college. Back then, I found the beauty of these trees arresting. It didn’t occur to me that the leaves were beautiful because they were dying. I stood under this canopy, staring at the example I often cited with patients: We are no different from the leaves of trees, blooming green for a season, drying and turning red the next. Rather than simply understanding this truth, I could feel its resonance throughout my body. Something filled my chest, widening and stretching. And for the first time in months, I wept, my tears mixing with the soft rain streaking my face. At a house across the street, I watched curls of smoke rising from a chimney. I thought of the morning years ago when I left the ICU and stared at the hills across the bay, ribbons of smoke unfurling from my cigarette. I remembered how it burned orange, then crumbled to ash.

A sidewalk outside a gray apartment building, a clearing in the forest, a patio: all places where I understood, in different ways, that everything goes from pattern to dust.

As I walked back to my hotel, I listened to a recording of “Medicine Buddha,” asking for healing, knowing that this would be the work of a lifetime:

Tayata Om Bekandze 
Bekandze Maha Bekandze 
Radza Samudgate Soha 

I wanted to believe that the vastness of the natural world became my refuge. It would be tempting to embrace this simple answer to a complicated question.

But I have come to see that refuge isn’t just a place. It is a practice. It exists beyond everything we can see and touch, beyond the rules of time and change because it is the deepest and oldest part of us. It offers the freedom we can find by surrendering to impermanence, understanding what endures and what does not. I needed to shift from an intellectual understanding of the fleeting nature of a tree or a sunrise to experiencing, through my body, how the only true permanence actually felt. I needed to hold the weight of grief, then to let it go. I needed to look at a canyon and learn to remain still. I needed to bow to the changing world, to understand that just as happiness passes, so does sorrow. I needed to understand, in an embodied way, that there is nothing fixed about my identity as a doctor, nothing within a hospital that could ever be a reliable home. And it was only by seeking the opposite of everything that the hospital required of me that I could see it for what it really was. I understood more clearly what will always be water through my fingers when I understood the nature of my hands themselves.

Through the practice of refuge, I have come to see that I am no different from the moon or a beetle or the vastness of the sky. I am a doctor, but I may not be tomorrow, should an accident befall me. I search for comets in the winter sky, knowing they will blaze and vanish. I love my family and my pets in ways that words cannot capture, but I know that one day I will lose them all and live alongside grief that transcends language. But beyond love and sadness and worldly identities there is something magnificent, something that exists at the coordinates of absolute stillness. When I feel it, I imagine that it fills the great hollow of my thorax, transforming it into a place filled with stars.