Medicine has always been about the process. In undergrad, we told ourselves that grinding on the MCAT was what we needed to do to go to medical school. Now, we tell ourselves that we need to grind in our preclinical classes to do well in our clerkships. Then, we’ll tell ourselves that we need to grind for our shelf exams to have strong residency apps, and in residency, we’ll tell ourselves that we need to grind for our attending interviews. Medicine is a profession with a uniquely high number of hoops to jump through, and as such, is a profession uniquely focused on the next step. Paradoxically, this focus on the future is what makes the awareness of the present that mindfulness prescribes more necessary than ever.
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As a POC, I attended a predominantly white private school from kindergarten all the way through senior year. As a kid, differences between me and my classmates were not always apparent, but as I grew older I found it increasingly tough to relate as one of the very few Indians at this school. This difficulty connecting, while not the fault of my classmates, made it challenging for me to form meaningful friendships throughout high school. My family life also contributed to my perceived difficulty in building close relationships. My home life was not the best at the time, and as a result, I struggled to build close relationships with my family as well. Regardless of where I was, I always felt out of place—I was not a happy kid.
As I got closer and closer to the end of high school, I realized that the same friends I saw every day, I would soon only see once every couple of months. The transient nature of not only my relationships, but also my reality stuck out to me. It hit me that when I left for college, and hopefully met diverse people from around the world that I had more in common with, my lack of fitting in in high school would be a distant memory. I knew that in just a few short months, I would miss the same family that I currently avoided. While the people around me stayed the same, my way of looking at them had changed drastically..
These realizations did not come to me because I had a particularly deep mind, but because they had been drummed into my subconscious. I had attended Balavihar, our local Hindu Sunday school. The high school Balavihar curriculum transitions from the ritualistic aspects of Hinduism taught in middle school to philosophy. Hindu philosophy is mainly focused on how our minds function, and how we can work to improve the way our minds function to optimize our relationship with the world around us. For most of this class, I thought this philosophy was interesting to learn about but didn’t really have anything to do with my life. However, when my mindset toward my life started to shift in high school, I realized how valuable these lessons were in my daily life.
During senior year, I started thinking about how there were two different layers to how our mind reacted to the world around us: the external world and the events happening in this world, and our internal interpretation of the world and its events. Most of my life up until that point had been spent fixating on what was “wrong” with the world around me and trying to unsuccessfully improve it. It was at this moment that I decided that regardless of who I met in college or what experiences I had, these next four years were not going to be the same as the past four. The way that I was going to accomplish this was not by doing everything I could to have an amazing college experience, but by doing everything I could to improve the way I looked at the world around me.
I dove back into the Hindu philosophy that transformed the way I looked at high school. Through this reading, I found an equation to quantify happiness that would prove to have a huge influence on how I have looked at life since:
This equation was found in a book called Self-Unfoldment, by Swami Chinmayananda. It fundamentally argues that there are two ways to increase your happiness: by increasing the number of desires that you are able to fulfill, or by decreasing the total amount of desires that you have. Swami Chinmayananda, paraphrasing from Vedanta (Hindu Philosophy), argues that almost 100% of our effort, due to the way that society is constructed today, is spent on maximizing our number of fulfilled desires. However, the fulfillment of desires is dependent on the world around us, and as we all know, the world around us is rarely under our control. Swami Chinmayananda argues that the more permanent way to maximize happiness is to minimize the number of total desires you have—as these desires exist only in our mind and therefore are theoretically under our control. This equation and underlying explanation is the underlying basis for the fundamental key to happiness according to Hindu Philosophy: detachment. After this summer of reading, I resolved to make detachment a key part of my outlook in college.
However, being detached is far easier said than done. Eighteen years of thinking is not something that is unlearned in one summer. Funnily enough, I found a way to help myself through this process in the last place I expected: the lab I conducted my research in. At first (and second and third) glance, a premed’s experience in a research lab seems like the antithesis of detachment. Many premeds only join a lab in order to tick one of the many boxes required to apply for medical school, and even among those who are actually passionate about the science, they are usually attached to the results of their experiments and the quality of their work. At first, I was very excited about the research I was doing, but my experiments repeatedly failed. While these repeated failures beat my passion for biochemistry and virology out of me, the process of troubleshooting unlocked the key to implementing detachment into my life.
In science, when an experiment fails, the first step is usually to sit down, think about each step of the experiment and examine both the steps and underlying thought behind these steps for any weaknesses. If you repeat this process many times (this repetition being necessary if you’re as bad at research as I am), you gradually improve the quality of your experiments. While working to fix one of my assays, it struck me that this iterative thinking should simply not be limited to science—it could be used to improve my mental process as well. As the professor of a mindfulness class I would later take said, “If science is the third-person way of learning about the world around you, mindfulness is the first-person way of looking at yourself.”
Up until this point, when I perceived negative mental energy in my head, I tried to fight back against it and beat it down. After that point, I tried to treat my mind like an object of scientific study. Just like I would not get angry at my cells for failing to beat back the virus, I accepted that my mind had some built-in bad habits. And just like I would reflect on and attempt to diagnose any weaknesses with my experimental designs, I could reflect on and attempt to diagnose any weaknesses with my mental outlook. For example, after taking a biochem exam that I had stressed out about, I took some time to think about why I stressed out about this exam, if it actually accomplished anything positive, and if it was possible to isolate these positive effects without the negative consequences that stress carries. In these reflections, I also tried to incorporate detachment. I thought about how little the exam really mattered in the grand scheme of things in my life—would 5-10% either way in 30% of one out of the 30 classes of my undergrad affect my life trajectory? Probably not.
An important nuance in the Vedantic idea of detachment is that it only applies to the external world and what is out of your control. Detachment is not apathy; if we take the biochem exam, it is within our power to prepare ourselves adequately and completely for the exam, but it is not within our power to determine what the professor actually puts on the exam. Detachment in Hinduism is defined as doing one’s duty without a desire for the fruit of one’s actions—this fruit is what one is detached from, because of the impossibility of controlling the external world.
This process of iterative thinking drastically changed the way I viewed life, and I was riding high for the first three years of college. But the mind is a fickle beast, and the world has a way of knocking you back down to the ground. My senior year of college was tough for me—I was heartbroken, grinding through the medical school application process while balancing a summer job and coursework was not easy, and as I’m sure every member of the class of 2020 can attest, getting unceremoniously kicked off of campus was fun for no one. Moments like submitting my thesis and graduation were rendered anticlimactic by taking place at my childhood desk and living room respectively and zoom codename nights took the place of my planned senior trip with friends.
It was through this low point that I realized that despite all of my best efforts throughout college, I was still remarkably attached to the outside world and that I was not nearly as far along on my mental quest for peace as I thought. With this sobering realization, and the fact that I had more time on my hands than I knew what to do with due to the pandemic and my lack of non-travel plans between graduation and medical school, I decided to take up meditation. Many of the texts I had read up until this point had espoused meditation, but I was a skeptic—I didn’t see how sitting in silence could help me improve myself, and since I always seemed to be busy, I was loathe to add an extra 20 minutes of practice into my day that at the time seemed pointless. Today, I am glad to report that I’ve realized just how wrong I was at the time.
Mindfulness meditation is predicated on picking an object of focus and attempting to maintain one’s focus on that object for the length of one’s practice. The object of focus itself doesn’t matter, only the meditator’s focus. It is accepted that one will be distracted at times, and that one’s mind will wander away from the object of focus, but the goal is that with time, one becomes more aware of their mind, the directions it wanders in, and is better able to shepherd their mind back to the intended object of focus. The goals of mindfulness meditation are twofold—to train one’s mind to stay in the present, and to transition from identifying with the mind to witnessing the mind.
If the mind is trained in this way, one can become much better equipped to deal with pain. Mindfulness posits that while pain is an inevitable part of life, suffering is not and stems from our inadequacy in responding to and compartmentalizing the painful (both physical and emotional) stimuli in our lives. When an experienced mindfulness practitioner encounters a painful stimulus, instead of identifying with this pain and fully experiencing it, they take a step back and witness the pain. Witnessing the pain from the outside allows one to characterize it, to rationalize it, and to diminish its impact. Moreover, the ability of the experienced mindfulness practitioner to stay in the present means that they are only existing in the moment, and while pain can be strung along through a long time period, they are only experiencing it at the present moment. Experiencing pain ephemerally is far easier, and thus, one’s suffering diminishes.
Additionally, the experienced practitioner’s ability to witness one’s mind at work leads to better impulse recognition and long-term perspective, which in turn leads to the realization that most of our objects of fulfillment of desires are themselves transient in nature. Even before applying to medical school, the application cycle seemed like a defining point in our lives, but 50 years from now, upon retirement, is where we attended medical school going to truly affect our happiness? And if it doesn’t affect our long-term happiness, why should it affect our happiness now? These types of questions may seem ridiculous, but all tie back to the experienced mindfulness practitioner’s ability to stay in the present—through witnessing the transient nature of the external world, there is no reason to stay anywhere besides the present. By decreasing their desires, this experienced practitioner is able to both decrease the amount of painful stimuli (which in one way or another can all be tied to the lack of fulfillment of a desire), and better deal with the stimuli that do cause pain in their lives. I want to provide the disclaimer that I am nowhere near the level of mental balance described above, but instead I am summarizing the goals of mindfulness theory and where I hope to be far, far into the future.
Meditation has helped a lot in my ability to contextualize the world around me, and I’ve seen benefits in my mental stability, focus, and resilience. I have grown to classify meditation as a form of exercise. Physical exercise is a way to condition your body to deal with physical stressors, and for me, meditation is a way to condition my mind to deal with mental stressors.
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So, what’s the point of this article and how does it relate to medicine? As we all know, the process of being a doctor can be extremely damaging to mental health. In my opinion, one of the main reasons for this is because the entire process of being a doctor is predicated around the future—it’s all about completing the next thing on your checklist or progressing to the next stage in our medical training. This focus on the future makes it almost impossible to stay in the present, thus weakening our mind’s abilities to realize the transient nature of our pain, therefore leading to mental suffering. This is why I believe it is uniquely critical for mindfulness to be a critical part of our lives as medical students. We go to class and study for hours a week to nourish our intellectual health, we exercise and eat healthy to maintain our physical health, but many fail to do anything to maintain mental health. Without mental health, how much are physical and intellectual health really worth?
Pranav Rekapalli is an MS2 at the Perelman School of Medicine.
