Healing Burnout

James Shaheen: Hello and welcome to Life As It Is. I’m James Shaheen, editor-in-chief of Tricycle: The Buddhist Review. Over the past few years, the pressures placed on healthcare workers have mounted steadily, and rates of burnout and exhaustion are on the rise. According to Jan Chozen Bays, a pediatrician and Zen priest, mindfulness practices can provide an antidote to burnout and support those who are working on the frontlines of human suffering. In her new book, Mindful Medicine: 40 Simple Practices to Help Healthcare Professionals Heal Burnout and Reconnect to Purpose, Bays presents short, simple practices to help healthcare workers reconnect with themselves and their patients in the midst of demanding workdays. In today’s episode of Life As It Is, my co-host Sharon Salzberg and I sit down with Chozen to discuss her own experience of burnout, her work in creating supportive communities for physicians, and how we can experience a greater sense of presence and flow in our daily lives.

James Shaheen: So I’m here with Jan Chozen Bays and my co-host, Sharon Salzberg. Hi, Jan. Hi, Sharon. It’s great to be with you both.

Sharon Salzberg: Hi.

James Shaheen: So Chozen, we’re here to talk about your new book, Mindful Medicine: 40 Simple Practices to Help Healthcare Professionals Heal Burnout and Reconnect to Purpose. Can you say something about the book and what inspired you to write it? 

Jan Chozen Bays: I’ve had two careers simultaneously, which were hidden from each other for a long time. So there was the medical career, but at the time I entered medicine, it was not acceptable to do meditation. It was considered woo woo and very weird. So there were only a few of us in the hospital where I trained who meditated, and we had a kind of secret society where we would pass in the halls and say, “How was your retreat?” And it’s very gratifying to go from being considered weird to then be considered a pioneer and then now considered mainstream. So my second career was obviously studying Zen and doing meditation retreats and becoming a Zen teacher. Those two careers in medicine and in meditation practice have finally come together. I think the reason I wrote the book is that burnout is becoming so common, and I myself went through an experience of burnout. I don’t think I could have survived in my medical career, especially doing child abuse work, if I hadn’t had my spiritual practice. So I just thought, if I have something to offer that will help people, then I’ll write about it.

James Shaheen: You begin with your own experience of burnout, first realizing that you were burnt out and then doing something about it. Can you talk about those two things? First of all, just realizing you’re burnt out. A lot of us don’t realize it until it’s far too late.

Jan Chozen Bays: Yes. Well, I was doing fine. I was probably one of the most resilient people and optimistic people in our child abuse unit, where currently, they’re seeing between 100 and 120 children a month for child abuse, and some of the cases are quite horrendous. I think what happened is that my father died. I had a very loving, supportive father. And then my root teacher, Maezumi Roshi, died. This is a common phenomenon in medicine, that we can cope with all the stresses of a medical career until something happens in our personal life and that tips people over. I didn’t realize at the time what was happening. I just was going home typically late on a Friday night because an emergency rape came in for a teenager. I finished that evaluation and I’m going home two hours late on the freeway at night. I remember it vividly. This really soppy song came on the radio. It was some country music song, you know, “My sweetheart left me” sort of thing. And I just began crying. More alarmingly, I thought, “I’m not sure I can stop crying.” And so it was like this well of sorrow and human suffering that finally broke open. And then I realized, “Something is really wrong here.” I also watched my behavior and realized I was showing up 5–10 minutes late, I was beginning to feel kind of combative with my best friends in the work, the person who was our administrator in our child abuse center. And also I was resisting seeing patients. So an emergency call would come in at five o’clock, and I would start thinking: Can we send it over to the emergency room? Can we see it tomorrow? So it was a kind of depersonalization of patients, like “Oh no, not another rape case in a teenager.” It becomes a case rather than a person. So evaluating all of that, I realized, I’m in trouble here. And I need to find out what this is because I’m one of the strongest people in our unit, and if I’m affected, then other people are going to get mowed down, too. So that’s when I began reading and discovering, oh, burnout.

James Shaheen: Yeah, how did you begin to find a way out of this? I mean, especially with child abuse and the horrendous cases that were under your supervision or care.

Jan Chozen Bays: Well, I needed more time for practice. It’s like the dose has to match the illness. Because I was working more than full time, as is common in medicine, I didn’t have enough time for practice even though I was kind of inserting practice. Driving to work, I would be chanting, or I would be doing lovingkindness practice for people on the road passing me. So I knew how to weave practice into daily life, but the dose wasn’t enough. So I pulled back to half-time, and half-time means you’re being paid to work three-quarters time for half-time pay. And then I finally realized I needed to step back for a while. So I stepped back from being the director of the child abuse program and increased the dose, let’s call it, of my spiritual practice.

James Shaheen: I was wondering if you could tell us one anecdote that is somewhat humorous. Your husband gave you a button that said “Just Say No” to help you set healthier boundaries. Do you want to say something about that? Because apparently you did not immediately succeed.

Jan Chozen Bays: No. So he’s a psychologist and also a naturopathic physician and also a Zen teacher. So you can see I was in flames, let’s say, and becoming short tempered and irritable and so on, which is just very not like me. And so he said, “You need to start saying no to people.” He gave me one of those “Just Say No” buttons, and I had it on. And then he would ask me every night, “Did you say no today?” And then I would think and I would say, “No, I didn’t say no.” So then he gave me a clicker, which they use sometimes in therapy so people can click their behaviors. I was supposed to click when I said “No,” and I would come home every night with zero on that clicker. That’s when I realized I really am in trouble. I needed something objective on the outside. So then I took up the practice of saying no, and it was so hard. The first time somebody called—you know, you get in a field, and sometimes you get put up on a pedestal, and you’re not that person and it’s very unhealthy. But people would call me and say, “We need you to be the keynote speaker at our International Conference on Child Abuse.” And I finally said no to one of those appeals. When I got off the phone, I was actually trembling. And so I realized, wow, I need to practice saying no more.

Sharon Salzberg: So much of what you’re saying is reminding me of pretty current research on the difference between empathy and compassion. I was always struck by the movement toward having empathy training, which is sorely needed. I mean, I think we see the coldness and the cruelty of the world without enough empathy in it. But I had done so much work at that point with healthcare workers or international humanitarian aid workers or people who worked in domestic violence shelters. I kept thinking, “These people have plenty of empathy. They’re burning out for some other reason. What is it?” Because really that sort of willingness to be on the frontlines of suffering and the care, I mean, it’s extraordinary. And the burnout is also extraordinary. And so I began looking at things like how much compassion for oneself is there in the midst of all this compassion for others, or exactly what you’re talking about, some boundaries. Can I admit I’m not going to be able to do everything by Tuesday and solve the world’s problems, some realistic limits and saying no. So compassion would be more like one possible response to that sense of empathy, which we definitely need. But it’s not enough. Because maybe, for example, we feel empathy in some situations, but we’re so exhausted to begin with, we don’t have any sense of any resource inside we can reach. So we can’t respond with compassion, we can’t move toward that person, that situation to see if we can be of help. So that all really came up for me in light of what you’re saying. I remember working with international humanitarian aid workers, and one of the things they taught me was that when someone is approaching burnout, the first thing that goes is safety regulations. Everybody knows that you’re in this refugee camp, you do not work over there, that’s precisely what people would start to do. So it was the self-care that really eroded very quickly.

Jan Chozen Bays: Yes, that’s absolutely true. And that’s why I included mindful self-compassion as an excellent way to work with burnout from over-empathizing, overidentifying with patients. And you have to be very careful. For instance, when I would go to autopsies on kids that had been murdered, I had to be really careful not to allow my mind to go to what were their last hours or their last days like. So I had to put up a boundary, as you said, so that I could do the clinical work that would help prevent this from happening to other children, what was needed for court essentially. Then later, maybe you can do compassion for yourself because your vulnerable parts are hurting, to know that this is going on and that this child suffered this way. It’s a kind of dance, a delicate dance, to be professional but then to take care of yourself.

Sharon Salzberg: And to know that that’s allowed.

Jan Chozen Bays: Yes, and one of the big problems in healthcare is now healthcare organizations have heard about burnout, and so they offer burnout seminars and workshops and resiliency workshops, but it’s like after hours. You have to stay for an extra hour. And that just adds to the stress. People need to get home and relax and go out and read in their garden or cook or take their dog for a walk, all the things that are renewing for themselves. The effort to help people with burnout is really laudable. But the methods aren’t working. Because I knew from my own experience how to weave mindful moments, moments of awareness, step out of the tangle of the mind and the distress of the mind, heart mind, I thought this is what we need. Some of them I call rescue remedies, where you’re in a bad situation and you have less than three minutes to refresh yourself to go in and talk to a family whose kid has just died in a drive-by shooting.

Sharon Salzberg: Throughout the book, you describe the pressure that’s placed on healthcare workers and the devastating toll that that can take, including higher rates of depression and PTSD and suicide. In fact, you say that health care workers are “working in the trenches of human suffering, experiencing things that other people do not ever want to experience or even hear us talk about.” So what are some of the unique stresses that healthcare workers face, both in general and in light of the pandemic?

Jan Chozen Bays: I think the pandemic just exposed what was already happening. For instance, there was a survey of nurses before the pandemic. It turned out that when they were being interviewed for jobs, previously, the question had always been “What will my salary be, and what will my working hours be?” Reasonable for a job interview. But now more and more nurses were asking, “How will you keep me safe?” And it used to be that there was a kind of cloud of protection around healthcare workers and a kind of almost reverence for health care workers. They were there to help you, and so you treated them well. But we had two nurses from San Francisco General come to one of our Mindful Medicine retreats. And they told me, they said, “We’re attacked on a regular basis by patients in the ER. At least once or twice a month, we get physically assaulted.” And one nurse said, “If I’m asked to draw blood from a patient, I will not go into the room without a security guard with me.” Now, that’s a very different change from how medicine was when I started doing medicine. So I think that’s one thing that’s exacerbated the problems. We go into medicine, maybe even unconsciously, expecting to be thanked for what we do and that people will recognize the sacrifice that we’re making: time away from our families, very limited holiday time, and so on. And so when we’re not met with gratitude, but we’re met with anger and physical and verbal attacks, it’s stunning to us. Then we begin wondering, well, is this worthwhile? And of course, the political divisions in the country and then specifically the divisions over vaccinations just exacerbated this. So one doctor who was working in intensive medicine was referred by his therapist to our Mindful Medicine group, and he just appeared and said, “I have to be here because I’m ready to punch a hole in the wall of the ICU” because he had a patient who was on a ventilator and had life-threatening COVID, not vaccinated, angry at the doctors that were there. The whole family was furious at the doctors and arguing that they wanted to take the patient home and give them some alternative remedy. There’s partly a moral dilemma here, a moral injury that we’ve also never faced before. What do we do? There’s a temptation to say fine, go home and give him ivermectin, do whatever you want if you’re going to be angry at me every day and think I’m killing the patient. In the past, people have been very accepting of the advice that medical people gave them in large part.

Also, I think we’ve talked about this in the Mindful Medicine group, but I think the underlying moral injury, frankly, is our healthcare system. When you go to Europe, they’re astonished that we don’t have healthcare for everybody. What kind of country founded upon the right to life, liberty, and the pursuit of justice doesn’t give basic health care or dental care or mental health care to all of its citizens? When I graduated from my training as a resident and went into practice, I thought, “Oh, well, in a couple of years, all the developed countries in the world will have socialized medicine and then I won’t have this dilemma of whether this patient can afford this test that they really need.”

Sharon Salzberg: Well, one term you use is chronic acute stress, witnessing highly distressing events without having time to recover in between. I can just picture the day in the life of a healthcare worker, and no break really significant, no inner rest if you don’t have the tools.

Jan Chozen Bays: Correct, especially in the ICU or the emergency room. What happened to us at our child abuse program is we had three horrible cases in one week. I mean, really horrible. I will not describe them to you. But one involved one of the Child Protective Services caseworkers whose own child was killed by a babysitter. So that brings it so close to you. Here’s this person you’ve been working with for years, and suddenly their child is a victim. So we called for help from our hospital chaplain, and she came over and explained this to us. She said it’s common in the ICU, where you get a kid in with leukemia, whom the staff has seen 10 times before and is attached to the family and the child, and then this time they die. And then they’re gone, and the next day, it’s a kid who drowned in a swimming pool. And then they’re gone, and the next day, it’s an automobile accident with a severe brain injury that the child will live but never recover from. And so, in a normal lifespan, let’s say your father dies, and you have time to mourn, and you have a year to kind of recover and come back to life not as you knew it, but a life that can go on and function well. But with this chronic acute stress, you have no time to recover. So it just builds up until finally, you just quit. I can’t take it anymore. 

James Shaheen: Frankly, I’m surprised that more of you don’t quit. I mean, the way you’re describing this, it’s sort of surprising that so many actually stick with it. You said it can be hard for healthcare workers to take time for themselves. I imagine that’s not an easy thing for any of us to do, but especially in this case, it seems essential. Why is it that it does take so long for someone to realize, especially a health care worker, that they are just beyond their limit. 

Jan Chozen Bays: Yes, I think for a couple of reasons. One is that most people go into healthcare because they want to relieve human suffering. Human suffering is infinite, as we know. Samsara doesn’t end. But you keep trying. You keep trying to end human suffering. And you realize the problem is bigger than you thought. And there’s the healthcare system. That, of course, leads to burnout. So there’s your vow, your original vow, your life vow: This is my chosen way to work in the realms of human suffering. Besides the vow, there’s the training, which in your medical school and internship and residency years and fellowship years, you’re taught the patient comes first. The patient always comes first. And yes, you have to stay late. And yes, you have to take the next emergency case that comes in because somebody else is called out sick. You know, it’s not about you, it’s about them. You’re taught that over and over again. And so we consider it selfish to think about our own needs.

James Shaheen: You introduce mindfulness practice as sort of an antidote to precisely what you’re talking about. So the healthcare worker can see where they are and that they are beyond their limit as a means of taking care of oneself. Can you say something about that?

Jan Chozen Bays: As I said, I could not have done especially the part of my career involving child abuse if I hadn’t had spiritual practice. What I learned was to weave these moments of open awareness, shifting from thinking mind to aware mind is what I call it, to keep refreshing myself, to keep letting go of the last patient, and being fresh as I opened the door into the next exam room or went into the next hospital room. It saved my life and saved my career. So I just felt like I have to offer this to people. The other thing we realized is that doctors and nurses don’t have time to talk to each other. So they have nobody to share this with, except grumbling on the side. But to sit down and talk about, for instance, the patient I will never forget. So that’s something we do in our Mindful Medicine retreats. Somebody else just listens, and you talk about the patient you will never forget. It’s never the patient that you cured and went home happy. It’s always somebody where you almost killed them or you left them disabled or you did kill them or you think your error killed them because the inner critic is huge in healthcare. And the reason is if you’re in a profession where a moment’s mindlessness or distraction can mean an error that will maim somebody for life or kill somebody, the inner critic is double strength, and it will pull out the filing cabinet like “Remember, in March last year, when you were distracted and gave the wrong dose of medication to this patient?” You will never ever do that again because you can kill somebody. Don’t you ever forget that. Or, at worst, impostor syndrome, like, what kind of doctor do you think you are when you make errors like that? Sharon mentioned earlier something very important, that it’s been shown by research that mindfulness training for healthcare professionals reduces medical errors.

Sharon Salzberg: I’m also thinking about the incredibly powerful role of community. This is going to sound perhaps very glib, given the seriousness of this conversation, but I also think about back in the pandemic where there’d be these videos of nurses just dancing and these explosions of joy, and it’s like the preciousness of life and cherishing connection and love. You see a lot of that too, that’s so hard to do alone. So in 2013, in response to the growing pressures placed on healthcare workers, you helped create a group, which you’ve referred to a few times, called Mindful Medicine PDX. Can you share more about the organization and the types of programming and support you provide for healthcare workers that has them dancing at the end of their shift?

Jan Chozen Bays: What we do at the end of our weekly meeting for an hour, actually, is I show a video that makes everybody laugh because one of my techniques now is to go to bed with a smile on your face. So you know, some cute kid or some little funny, very short video. But the group started, it was very interesting. A couple of physicians at one of our hospitals, Providence Hospital in Portland, took Mindfulness-Based Stress Reduction courses, and they felt that helped them so much. They were ready to quit medicine, and it just renewed their ability to come back into this profession that they love. So then they teamed up with two of the MBSR teachers, who were also Zen practitioners, and said, “Let’s develop a Mindful Medicine retreat.”

So they started doing that twice a year. And it was hugely helpful. Because when people tell the story of “the patient I will never forget,” they weep, and we all understand. I’m getting choked up thinking about it, actually. We all understand their sorrow, their deep sorrow. And just to be able to share that because you don’t have time to do that in this profession is hugely healing. And then they’re taught basic meditations, what we call rescue remedies for times of acute stress. Sometimes we get people back in touch with their original vow, the reason they went into medicine. So this has been hugely helpful. And some people actually come once and then we see them again on our weekly meetings, an hour from 8–9 at night, when people usually have had time to get home, get their kids fed or themselves fed, do whatever charting they didn’t have time to do it work, and then they can come. One physician says, “If I come to this on Wednesday night, I always sleep better.” It just gradually built out of this small cadre, who also did a study which was in a scientific journal about the benefits of mindfulness training, and now the literature on the benefits of mindfulness training is extensive. The book has over 200 references, because medical people like evidence-based information, so I had to do that.

Sharon Salzberg: Do you have any recommendations for healthcare workers looking to find community support? Because I can remember, I think the first clearly delineated group of caregivers I worked with were frontline domestic violence shelter workers doing this program through the Garrison Institute. We made a point of trying to have at least two staff people per shelter so that it wasn’t just like one person all alone making these experiments, and it was really fascinating to me, because one of the things I learned was how rarely people spoke to one another about the conditions of their work, even though they were all doing the same work. It almost never happened.

Jan Chozen Bays: Yes, correct, isolated in the midst of working with other healthcare professionals. It’s really strange, but that is the way it is. So just to get together once a week and talk and pick up a mindfulness practice and then talk about that next week. The two MBSR teachers, who are cofacilitators of our Mindful Medicine group, say breakout groups are the secret sauce of our meetings because people get to talk to each other. You know, together, we can share a burden. But when you feel completely isolated, you feel like you have no place to turn. And it’s kind of that code of “I’m strong, and I can take care of this myself.” That will lead to burnout.

James Shaheen: Chozen, you mentioned earlier that you needed more time for practice. That was one of the things that you realized. Yet one of the most commonly cited obstacles to developing a mindfulness practice is lack of time. Can you share more about how healthcare workers can fit mindfulness practices into their routine, even on the busiest of days?

Jan Chozen Bays: Sure. In the book, I have a group of practices for healthcare workers to connect back with themselves because we end up in our heads and running around, and so connect back to body, heart, and mind. For example, one is “Wash your mind while you wash your hands.” We have to wash our hands so many times a day or sanitize our hands so many times a day. It’s perfect. Just stop, and as you’re washing your hands, feel your hands, come into your body, and then just let your mind become clear too. So then you have, I don’t know, 20–40 opportunities a day to just stop for a moment, drop into what’s actually happening, and clear your mind, clear your heart mind. So people love that one. Tenzin Wangyal Rinpoche, a Dzogchen teacher, has this practice of the three pills. So it’s perfect for healthcare professionals: Take your pills. The pills are to develop a place inside of you that is silent and undisturbed by noise or thoughts, to develop a place inside of you that is still and is undisturbed by movement, and then finally, the third is to be able to open your mind into wide-open awareness.

So if you practice that and you do develop a kind of a physical sense, for Zen people that usually their hara or their dantian, a physical place where you can drop from here down into that physical place, silence, stillness, even for a few moments, and then open into wide open awareness, that alone is such good medicine. But it takes practice. All of this takes practice. You can’t just do it a few times and then move on to something else. It’s got to be there when you need it. So of course, gratitude practice, we know the benefits of gratitude practice. That’s really well documented. So people love to do gratitude practice, and not just, “Oh, at night, I write in my journal what I’m grateful for during the day,” but during the day, at this moment, this standstill, what am I grateful for this moment? Well, I’m grateful that there’s 21% oxygen in the air, for example, and the trees are giving that to me.

One that I invented, which people turn out to love, is called “A Life of Continuous Prayer.” So we think that continuous prayer is confined to convents or monasteries where people are cloistered. But there’s a way to do it in your daily life. So let’s say you’re walking across the hospital campus, and you see a tree, and you just say, “Thank you, tree, for giving me oxygen, and I hope you enjoy the sunshine today.” It doesn’t have to be a certain kind of religious prayer. Or as you leave the room from seeing a patient, “May you be restored to health in body and mind.” It can be very simple. People turn out to love this practice of continuous prayer.

And then some of the exercises are to connect you with your patients because the research on patients shows that the two things that they’re most afraid of are depersonalization and loss of control. If you’ve ever been a patient, you know how that feels. It’s good for healthcare workers to be a patient because then they get first-hand experience of what that feels like. So some of the exercises are designed to connect in a personal way with patients. Electronic medical records, which were touted as going to be the savior of the healthcare profession, are driving healthcare professionals crazy because you’re looking at a screen and you’re filling in boxes, and meanwhile the patient’s over there behind you. So ways to connect. One is to ask about pets. It’s amazing. If you ask about pets, or they don’t have a pet, plants, do they have any plants? Then people feel recognized as an individual, and they just brighten up. They love talking about their pets. You know, what’s the name of the pet and can they do tricks, and then you open up this hole. It just takes a minute or two. But then you put that in your notes, and the next time they come in, you say, “How is Buster doing?” Then you recognize them as a valuable individual and caring for their life, not just what’s on the lab sheet.

And that reminds me of another really popular exercise for connecting with patients. It’s to talk about what’s working well. So our tendency is when a patient comes in, we say, “Oh, let’s see, you had some lab work from last time. Let’s look at your lab work. Oh, dear, your liver enzymes are elevated. That’s not good.” So you start with the bad news. That’s terrible. You have to have a sandwich of the good news and then what needs to be worked on and then the good news. So what we do is we look at the lab work and we say, “Wow, this is great. Your pancreas is doing such a good job of regulating your glucose. It monitors it continuously and adjusts the amount of insulin that it puts into your bloodstream. Isn’t that amazing? You’re doing a great job. Your kidneys too.” So you just start with all the strengths, all the positives, and then you say, “Oh, now we need to work on. You’re a little anemic. Maybe you need some iron.” People have found that patients come in afraid that something’s going to be wrong. If you start with what’s working, it not only educates them, but it really supports them in realizing their body is 98% doing great or 90% doing great. Jon Kabat-Zinn actually taught me this because he had long ago, when he first started teaching MBSR, a videotape that hospitals can play for patients who are awaiting surgery, and it was all about how 95% of your body is working so wonderfully. The human mind is attracted to the negative because that’s what you have to worry about, and that is what causes our suffering.

Sharon Salzberg: I think you’ve given me my new absolutely favorite phrase, which is wash my mind. I’m going to go wash my mind now for a few minutes. It’s a great feeling. I like that. I also want to go back to something you mentioned earlier when you talked about the inner critic, which I find a fascinating place to work. I think it’s pretty clear why this could be especially strong amongst healthcare professionals: the mistakes, as you mentioned, can be extremely consequential, the standards are high, the pressure is enormous. But working with the inner critic is where so much creativity and possibility arises. I know something we often tell people in the Burmese tradition is you have a fierce and very present inner critic or often visiting inner critic. Maybe give it a name, give it a wardrobe, give it some personality, because how you relate is going to be the whole point of the exercise. It’s just easier to relate in those ways. So I’m curious about ways you suggest people work with that.

Jan Chozen Bays: Exactly what you said. So you need two degrees of separation from the inner critic. First, you bring it out so you have two degrees of separation from it. Then you separate from it even further. We have people draw a picture of their inner critic and name the inner critic. Does it speak in masculine or feminine type voice, and whose voice does it remind you of? We show the impossibility of meeting the inner critic’s demands or the perfectionist’s demands. They team up. The perfectionist, the pusher, and the inner critic all team up. And the pusher is extremely strong in medicine: do more, don’t go to sleep yet. There’s a common phenomenon in medicine. You go to sleep for 10 minutes, and you wake up all alarmed like, “Did I give the right order? I got to go out and check the patient again” when you’re on call at night. So the inner critic will wake you up. So one person shared that when they awaken in the middle of the night and they start thinking about all the things they might have done wrong or forgotten, then this person said, “What I do is I say to that voice inside, ‘I’m not willing to talk to you until the sun is up and I’ve had my coffee.’” Another person said, “What I do is I imagine a really high shelf, and I take that whole bundle, and I put it on a really high shelf.” And she said, “I’ve had to practice this. It took about two months of practicing it before it’s now automatic” and you’ve escaped from the clutches of the inner critic. But ultimately, the inner critic, if it’s shorn of its personal sting, is discernment. And so to help people uncover the discernment that’s in there about “Oh, yeah, I almost gave the wrong medication. What can I do in the future to prevent that from happening?” The old cliche, mistakes are an opportunity to learn rather than an opportunity to beat yourself up for the rest of your life.

James Shaheen: So Chozen, I’m about to quote you at length from your book, I hope you don’t mind. “The inner critic depends upon invidious comparison, upon ruminating over past mistakes and anxiety for the future. When we let go of past and future and ride the current of moment-to-moment awareness, the inner critic disappears. It has no traction in the present moment. Any activity in which we become so absorbed that we lose track of time, hobbies, playing with children or pets, time in nature, arts and crafts, all help us step aside from the inner critic. When we are able to put aside the cacophony of thoughts and enter now at ease within the flow of time, the inner critic vanishes. It is transformed into inner curiosity and wonder of discovery.” Can you share about this sense of flow is what you’re describing and how we can tap into this sense of wonder and curiosity in the midst of our day-to-day lives?

Jan Chozen Bays: That’s the ultimate magic of meditation practice. I call it learning the door that walks you into the present moment. And there are infinite doors, of course. Once you learn how to open that door and walk from thinking mind into awareness mind, you’ve got the solution to your own suffering and then to being able to help other people because the inner critic doesn’t exist in the present moment. It depends on the past and endless rumination over the past. I tell people we wouldn’t rent the same bad movie 250 times. But we do that in our own mind. And then the future, of course, is all imagined. And most of the futures we imagine don’t come the way we imagined them. So do your planning, use the mind for its abilities, for its talents, like booking an airline flight or calculating a dose. But don’t use it the rest of the time. Learn how to turn it off and walk into wonder, flow. And everybody’s had an experience of flow. So it’s not out of reach. This is really important to say. We’ve all had what we call peak moments. And then I get people to tell me how those peak moments occurred. Those are what I call the over-the-counter remedies: being in nature, being absorbed in a hobby, playing with children who are in the present moment or animals that are in the present moment, being in the garden and just forgetting time, watching a sunset. When you watch a sunset, you’re totally transfixed. Then somebody says, “Oh, I saw a better sunset in Hawaii two years ago,” and then the moment crashes, right? So to learn to walk out of thinking mind into flow mind or awareness mind is the medicine. It’s the ultimate medicine.

James Shaheen: Yeah, you refer to this as “a sense of unobstructed life.” I thought that was especially nice.

Jan Chozen Bays: And we’ve all had that. We just don’t know how to do it on purpose until we have a meditation practice and until we go to retreats, frankly. I think when you go to retreat, then it goes deeper, deeper, deeper in you every time. But a lot of doctors don’t have time for retreats. So our retreats are just a weekend retreat. They come on Friday night, then they don’t have to come till 10am on Saturday. We have a time so it fits their schedule and allows them to be with family, exercise, call in about patient care, and so on. So we have to adjust to the way medicine is right now in order to transform it from within.

Sharon Salzberg: There are so many uses of the word purpose, including our sense of meaning in life, and that’s a theme that runs through your book quite a lot. You write, “The purpose of our life is to learn to relieve our own suffering, to completely understand and love our own self, and then to find a way to help other beings or other people who are suffering.” Can you share some more about this definition of purpose and how it’s informed your work and healthcare workers?

Jan Chozen Bays: Yes. So it doesn’t, of course, apply only to healthcare workers. Everybody has their place in relieving human suffering. A man who comes once a week and collects our garbage from the monastery. What would happen if he didn’t do that? Or the plumber we call when the plumbing is broken, or our well filled up, and we had to have it redrilled and adjusted. There’s just so many examples in our life. But people want something different. And that sense of dissatisfaction we hope will drive them to spiritual practice. It doesn’t have to be Buddhist, of course. But that’s what people are longing for. That’s what’s calling them from the inside. This has to be taken care of. Because you can have patients who have gotten a cancer diagnosis, and, as one of my friends did, walked out from the doctor’s office, where she was told she had breast cancer, and she said the whole world was brilliant. She could see every leaf in exquisite detail. So that’s what knowing about death helps us do. That’s the kind of thing we can help people access throughout their life. But it does take practice. And that practice takes time. And retreat practice definitely takes time. So it would be lovely if healthcare organizations, instead of having a weekend retreat on resilience, would just say, whatever your spiritual tradition is, go and do a week of retreat, whether it’s Ignatian practices with the Jesuits, I don’t care what it is. But just get out of your venue and out of your mind and into your body and your heart.

Sharon Salzberg: And let’s talk about love, a beautiful thing to talk about. You define love as “the desire for another person to reach their own highest potential and the willingness to sacrifice what we want in order for that to happen.” It’s also a very rigorous definition. It’s very demanding of oneself.

Jan Chozen Bays: Yes, it is. So I came up with this definition because I was pondering this desire for a soulmate, that everybody’s dissatisfied with their relationship because this is not their soulmate and they’re looking for their soulmate. I’m just like, This is not how it is, folks. So I really pondered at length, what is true love. And that’s what I came up with. Because if we really love someone, whether it’s a partner or spouse or child, life is going to ask us to sacrifice what we wanted for them. Because my parents were teachers, my father was an academic, my grandmother was an academic, I was an academic, I just thought, “Oh, my kids are going to become academics,” and they’re like, “Absolutely not.” And so I had to see, okay, what’s the fundamental? I want them to be ethical people who do something in the world to benefit others. That was the bottom line. And I’m willing to help them however I can accomplish that.

James Shaheen: So it was left to Sharon to ask about love, and it’s my turn to ask about anger. Sharon thinks that’s funny, and so do I. So another theme that runs through the book is anger. So can you share some of the unique sources of anger that healthcare professionals have to contend with?

Jan Chozen Bays: So we’ve done some workshops on anger and come to the conclusion—it wasn’t my conclusion, somebody said this. It was a participant, and they said, “I’ve realized that anger is the messenger that something is out of kilter. But it is not the means to fix it.” And we know that, of course, from the Buddha’s teaching, that anger just generates more anger in response and that love is the way. Of course, love is an overused word in our society and always implicates or implies romantic love. So that’s a big source of confusion. So working with anger as a messenger that something is off kilter. It could be externally, it could be internally, or it could be our reaction to the external. What I found helps me with anger is to seek its source. Our precept is not to release anger but to seek its source and ultimately dissolve its source. So I have people look at what’s the fear under anger because in my own discernment about anger, there’s always a fear underneath. If you can find that fear, then you’ve got your grasp on something you can work with, like patients’ fear of depersonalization. OK, we identified what they’re afraid of. So we can reduce the incidence of anger in patients if we address that directly. During COVID, anger became more overt in the healthcare professions. I’ve never seen this happen before. People get frustrated with a patient who won’t comply with their recommendations and so on, but not anger, not overt anger, like the guy who said, “I’m going to punch a hole in the wall of the ICU.”

Part of it is that we have always taken care of anybody who came in under our care. We didn’t know how they voted. I’ve heard Israeli doctors say, “We care for a body that comes in, an injured body, and the only way we will know if this is a Palestinian is if they’re not circumcised.” So that’s always been our approach: here it is, it needs caring for. But now, suddenly, we are aware of how people voted. And they’re aware of how we voted. And we’re aware of their attitude towards vaccinations, which may seem absolutely ridiculous to us. But we have to sidestep that. We have to have a way to release that anger and see what our fear is. I think our fear in medicine is partly that I’ll have to quit. If this goes on, I’ll have to quit my beloved profession. But if we don’t know our fears, then they’re always in there stirring. We don’t even know we’re angry. It’s always in there stirring. In our practice, we look at things directly. What’s going on in there?

James Shaheen: Yeah, I’m thinking about a piece that one of our writers wrote, and certainly I understand that if you’re advocating for a patient, this is from the patient’s perspective, you’re advocating for a patient, you’re dealing with a medical establishment that can be very frustrating, not only for the healthcare workers, but for the patients, and she talks about anger allowing her to just stand up and say, “I’m going to advocate for my brother, and here’s the attention that he needs or doesn’t need.” So I’m wondering what the limits of anger are. I discovered personally, quite to the contrary, that when I expressed anger in advocating for a patient, I became another one of those angry advocates that they could sort of push aside. But the anger might make me stand up and screw up the courage to speak to people who know far more about the situation than I do. But once the anger is expressed, you lose the person.

Jan Chozen Bays: Yes, you do. That’s exactly right. So how to clean up the anger and just turn it into determination. And that’s where our practice can help us. There’s a site called The Happy MD by a physician who is a consultant to other physicians, and he has this webinar on how to work with your administration without being labeled a troublesome and disruptive physician. So that’s what you want to avoid if you can. I listened last night to a Hidden Brain episode on healthcare. It was done by a physician. Her name is Vivian Lee, and she’s a healthcare executive. The podcast is titled “Slaying the Fee-for-Service Monster of American Healthcare.” She said we’ve gotten ourselves into this terrible situation where we pay for services rather than for the care of the patient as a whole. And our outcomes are terrible compared to other countries, and our costs are 2–5 times the cost in Europe or in Japan. And it’s because the more tests you do, the more services you do, the more you get paid. And so that becomes a driving factor rather than care for the patient. They start out the episode talking about a patient that they realize had been to their ER 52 times in one year. That’s like every week. And the expense was enormous. Sometimes she came in because she had healthcare problems, and sometimes she was just lonely. And so they take on her care. What does she really need, rather than this every incident, we got to do more tests, which is objectifying the patient. They’re not a person anymore.

Sharon Salzberg: Throughout the book, you provide 40 mindfulness practices that are catered to healthcare workers, and many of the exercises build on already existing components of a physician’s day, like washing your mind while you’re washing your hands. Can you speak a bit about the process of developing these exercises? Are there any that particularly resonate with the people you’ve worked with? I know it’s, of course, not just for healthcare workers but exemplifies taking something like an existing activity and bringing it to life.

Jan Chozen Bays: Yes. You know, I test these all out on myself. It’s a time-honored tradition in medicine: Test it out on yourself first. Then I take it to our Mindful Medicine group, and now we’re practicing one each month. Then I get feedback, and I ask, “What are your favorite ones, and which don’t work so well?”

Wash your mind when you wash your hands, that’s a favorite. A mindful walking path is also a favorite because healthcare professionals are constantly walking down corridors and halls or running from one building to another. And so if you can just take that, I used to do it from my car to the Child Abuse Center, which was up three flights of stairs. Instead of taking the elevator, I would do mindful walking up the stairs just to refresh myself before I got there. And I also did lovingkindness on the way to work for myself and my coworkers and the unknown patients and families I would be working with during the day. It doesn’t take that much time. It’s woven into the drive with an occasional watch of the guy who cuts you off on the freeway, and then you can say, “May you arrive where you’re hurrying to safe and healthy.” But it made a huge difference in the day for me to do lovingkindness on the way to work for myself and for everybody else. But people have to try it for themselves and see that it works.

Nature bathing is a big one that people have usually discovered on their own. But it doesn’t mean you have to go out into the wilderness for a week because there are trees everywhere. There are plants everywhere, even on your windowsill. We had somebody who was during COVID confined to their apartment, and they did it being with this plant, really getting to know this plant, loving this plant and seeing that it’s also loving you.

First three bites, first three sips. Healthcare professionals don’t have time for lunch, for example, which isn’t good for them, of course, and then there’s junk food around, because people bring it in, and so they’re eating junk food. So just to ground yourself when you begin to eat and pay full attention to the first three sips of your coffee whenever you’re drinking and then the first three bites. Then connecting with patients, besides pets and plants. There’s a huge volume of literature on the benefit of pets. We should be prescribing pets for patients.

Sharon Salzberg: I’ll take the puppy. James has a puppy. Well, it’s not exactly a puppy.

James Shaheen: He’s a big dog.

Jan Chozen Bays: Or if you can’t have a dog, somebody else’s dog that you have frequent contact with, then you take it for a walk. Asking about hobbies too. The literature on the benefits of hobbies is huge, and a lot of healthcare professionals don’t have time for hobbies, which is part of what’s killing them. It’s an instant connection with a patient if you ask about what their hobbies are. Asking about fears and worries. We don’t do that in medicine. We don’t say we’re afraid. Actually to say, what is your biggest fear about what’s happening to you right now or what I’ve just told you, because their fears could be completely different from your worries and totally unrealistic, and you have a chance to discover that and explain things to them.

Sharon Salzberg: I’m also just curious about the practice of loving touch. 

Jan Chozen Bays: Loving touch, yes. We’re often touching with a mind that’s directed towards do I feel anything abnormal, rather than a loving touch. And that loving touch is not hard. You just send the heart’s wish down to your fingertips and you’re gentle like you would be with a baby or your grandmother who’s sick. I think that can make a huge difference in you and in patients’ perception of how you’re touching them. You know, I have this whole exercise, it’s not in the book, but it’s an exercise of switching from your mind seeing things and commenting on things to your heart. How does your heart see this? And it’s profound when you do that exercise. So we’re trying to bring the heart’s gentleness and kindness into our encounters with patients.

James Shaheen: So another practice you describe is “This person could die tonight,” where you greet each patient, you briefly look them in the eyes and remember that they could die tonight. So how has this exercise informed your own work as a medical provider, as well as your life more generally?

Jan Chozen Bays: Yes. So we of all people know that this person could die tonight because we’ve encountered it, people found dead in bed. One of our receptionists at the child abuse program went home to check her husband who had the flu, and he was dead in bed. And so we know that this can happen anytime. But we kind of push it away because death is the enemy, right? Healthcare professionals often fall into a sense of invulnerability to all the illnesses they see. They have to protect themselves. But when you bring that awareness into your encounter, it just automatically drops you into lovingkindness for this dear human being whose life is ultimately fragile and could end at any moment. And then you bring it into your encounters. Like I now try, even if my husband’s leaving and we’re going to be separated for a few hours or half a day or a day, I try to bring not the kind of morbid awareness of “this person could die tonight” but just the preciousness of this could be our last encounter. Can it be a loving encounter? Can I say something I appreciate about him? And I try to do that as part of gratitude practice at night as we’re snuggling in bed, just to say something I appreciate about what he did during the day. Of course, the benefit is he has to say something back to me. He feels obligated. So we laugh about that.

James Shaheen: Jan Chozen Bays, thank you so much for joining us. For our listeners, be sure to pick up a copy of Mindful Medicine, available now. We like to close these podcasts with a short, guided meditation, so I’ll hand it over to Chozen.

Jan Chozen Bays: So settling yourself in your chair if you’re sitting in a chair or on the floor, and bringing full awareness to the body, this body that sits and breathes. And if your eyes are closed or you’re not looking at your body, how do you know that this body is sitting and breathing? What’s the raw data that tells you? Touch? A series of touches that we call movement? Areas of light pressure, no pressure, firm pressure? Perhaps sounds. The body does have sounds. You might be able to hear your own pulse.

Or your digestive system working so hard to absorb, digest and absorb food and put it into your bloodstream so it flows to your cells. Becoming fully aware of this wonderful body that night and day is taking care of you. Billions of cells, including cells that we call not our own, our microbiome, taking care of us continually. Can we send them some lovingkindness, all of these hard-working cells, our heart pumping blood, our lungs bringing in oxygen, getting rid of carbon dioxide, our liver and our kidneys cleaning our blood continuously of toxins, harmful substances, our pancreas, adjusting our blood sugar so delicately throughout the day and night, this amazing nervous system, sending signals all over the body, the cells that produce hormones that enable us to enjoy sex, enjoy eating, have pleasure in life, and the hormones that help us maintain equanimity. So you might send a silent thank you to your body for caring for you so well. And then if there’s a part of your body that’s having trouble or not functioning so well, please send some extra loving kindness to that part of the body. It’s just trying its best. And now, a few last deeper breaths. Maybe prolong the exhale a bit. If your eyes are closed or lowered, open your eyes and take in what’s in front of you. Look around the room with a sense of wonder like you’re seeing it for the first time like a child. Thank you for doing this meditation together.

Sharon Salzberg: Thank you.

James Shaheen: Thank you so much, Chozen, and thank you, Sharon. It was great to talk to you both.

Jan Chozen Bays: Yes, it was wonderful.

James Shaheen: You’ve been listening to Life As It Is with Jan Chozen Bays. We’d love to hear your thoughts about the podcast, so write us at feedback@tricycle.org to let us know what you think. Life As It Is and Tricycle Talks are produced by As It Should Be Productions and Sarah Fleming. I’m James Shaheen, editor-in-chief of Tricycle: The Buddhist Review. Thanks for listening!