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Toxic Success and the Mind of a Surgeon
Paul Pearsall, PhD
Arch Surg. 2004;139:879-888.
ABSTRACT
In his role of invited lecturer to the 75th Annual Meeting of the Pacific Coast Surgical Association in Maui, Hawaii, Dr Pearsall shared some of the results of his clinical study of highly successful persons and how their success and their pursuit of it often resulted in health and family problems. He highlighted 15 of his findings related directly to the physicians and surgeons included in his sample and suggested that healthy success is related less to time management than attention management. He pointed out that hard work, time pressure, stress, and a demanding schedule had less of a toxic effect than a lack of mindful engagement with life and those with whom we share it. He concluded with 5 ancient Hawaiian principles of healthy success Hawaiian style, the concept of po'okela, meaning achieving excellence through mindful awareness of shared values rather than individual objectives.
INTRODUCTION
We often get so caught up in the drama of our lives that we forget that we are the ones who created the drama in the first place.—Matt Flikstein
THE QUESTION OF SUCCESS
I begin my discussion of the toxicity of success by asking you to ask yourself a question. It was the first question we asked of the subjects in our clinical interviews of highly successful people, and it provided us with insight into the effect of how they defined, pursued, and experienced success.
Think of the person who knows you best. It may be your spouse, a sibling, a parent, a colleague, a friend, or your child, but make sure the person you are thinking of is someone who knows the real you better than any other person in your life. Think carefully before answering because our research indicates that your answer is a key predictor of whether you are suffering from toxic success syndrome. Here's the question: "Would the person who knows you best say you are a true joy to live with every day?"
If you answered a sincere and honest "yes" to my question, chances are your success and how you are seeking it are healthy for you and your family. If you scoffed at the possibility that you are someone with whom it is a treasure to live, work, and love; could not think of someone who knows the real you; or your mind was too distracted with thoughts about being on time for your tee time for golfing after this morning's meeting to be bothered by such a question, you and those with whom you live may be victims of toxic success.
THREE MEN AND A TRUCK
During the time I was reviewing and writing my research protocol on successful people, I met 3 men. I was on my morning walk with my wife, and I noticed them hard at work. It was another sunny day in Hawaii, where the air is usually fresh and invigorating, but today I could smell a foul odor. It was coming from the work the men were doing, and my encounter with them provided a lesson about the difference between toxic and healthy working and the relationship between healthy success and our state of mind.
I saw a large tanker truck with a long black hose draining the septic tank in front of a home. On the panel of the truck just beneath the professional lettering of the company name was an amateur drawing of a smiling worker holding a shovel full of waste. The slogan beneath the cartoon character read, "Call us. We're willing to take your crap."
I walked over to the man at the rear of the truck. He was holding the lever that powered the pump and had a frown on his face. He seemed bored and eager to be done with his task. We began what we Hawaiians call "talking story," taking plenty of time to chat about nothing in particular and with no particular hurry to get to a point even if there is one. This is a process that frustrates the toxically successful, who often view time as money and dread what they consider to be wasting any of it by engaging in activities such as chatting, strolling, meandering, sauntering, or just—as we put it here—hanging loose. Talking story as I am doing even in this lecture requires the kind of slow thinking that can be an antidote for toxic success. I highly recommend you try it while you are visiting our islands.
Certainly in work such as yours as surgeons, there is a place for what cognitive psychologists call "hot-and-go" quick thinking, but research shows that some of our most creative mental work and healthiest physical states are associated with "cool-and-slow" mindful reflection. Bristol University Prof Guy Claxton refers to these 2 states of mind as "hare brain" and "tortoise mind," and my own research indicates that it's chronic hare-brained thinking that is at the root of success that turns toxic.1
The man controlling the pump's motor seemed impatient and even a little angry at my distraction. He clearly had very little attention to spare and seemed irritated with me for trying to take any of it. "Howzit?" I said, which is island-style talk for "How are you, what are you doing, and would you like to talk awhile?"
With a sigh of disgust and without looking at me, he curtly said, "See the name on the truck? That's me. I'm the owner of the company. If you need your tank pumped, reach in and take one of my business cards from the dashboard."
"No thanks," I said. "But this must be very hard work."
Again without looking at me, he began a diatribe it seemed he must have given many times before.
When you're the guy who pays the bills, it's more than hard work. It's a hell of a way to make a living, but it puts food on the table. I'm on call for emergencies 24/7, I'm responsible for everything. The whole job is always in my hands. No matter how many jobs I do that go right, one wrong move and it's a disaster. Everybody needs what I do, but nobody really wants me to do it. They complain about the cost and think I make way more money than I do. Just my insurance alone costs me a big chunk of every cent I make and it goes up every year. I have to work most of the year just to pay my premiums. Nobody needs or wants me unless their life is in a mess, and then they want me right then and there. I have to deal with all kinds of stupid regulations and waste my time filling out tons of useless paperwork required by the government that doesn't know s___ about what I do, and . . . .
He stopped talking suddenly, swore, threw the wrench he had in his hand to the ground, and slammed a gauge with his fist. "I can't waste time talking story now," he said as he looked at his watch and went back to aggressively pushing and pulling various levers. As I stand before all of you surgeons today, it seems on reflection that his job description may not have been totally different from your own.
Another worker was standing on top of the truck's cabin and shouting the boss's orders to a man holding the hose in the front yard. "You want to know what my job is?" he said loudly. "I pump crap," he said. "It's as simple as that. It's the most rotten job in the world and I'll bet a guy like you would never think of doing it."
The negative energy of the 2 men at the truck, what Hawaiians call mana, was palpable, so I walked over to another worker struggling to control the heavy pulsating hose. The noxious smell was strong, but he was whistling happily. When he saw me approach, he looked up and said, "Aloha kakahiaka! (Good morning.) Aren't you going to ask me what my job is? I'm an environmental protectionist. Someone has to take care of the 'aina(earth) and get rid of the crap people create." He laughed heartily as he began to retract the hose from the tank.
How do you like the slogan I painted on Dave's truck over there. He hates it but he's too cheap to have it taken off. Dave's busy earning a living, Fred sees himself as a crap pumper, but I'm a hands-on ecologist. They have bad mana because they think of their work in a bad way. If you want to love your work and enjoy life, it's a matter of your point of view.
ARE YOU MINDFUL OR MINDLESS?
Much of the focus of research on stress and work has been on things like time management, various stress management techniques, trying to "live in balance," somehow "cutting back," or "putting in quality time," and how to avoid being a "type A" personality. My own research indicates that these approaches seldom work for long and that it is the nature of our consciousness that has the most significant influence on whether our work and view of success causes our families and us to flourish or languish and what that success ultimately does to our health and well-being. When it comes to the effect of our work on our life, a key factor seems to be whether we are mindless or mindful in our approach to our daily life. In other words, it is less what we do than how we think about what we are doing and why and for whom we do it.
Psychologists define mindfulness as flexible, slow, nonjudgmental, reflective thinking that is open to novelty.2 It is full mental engagement and the exact opposite of what Buddhists call a "monkey mind" that automatically reacts without thought. It is tortoiselike thinking that is sensitive to context and perspective and situated in the present.
When we are mindless, we tend to perceive without consciousness. In other words, we are thinking on automatic pilot. Psychologist William James described an example of someone who goes upstairs to change for a party and suddenly realizes he is in his pajamas and cleaning his teeth. You may have poured hot water into the sugar jar, used pepper instead of salt, or lit your fireplace logs with today's newspaper. There is a story of a vicar who dreamt that he was delivering a sermon and woke up to discover that he was.
Thinking mindlessly is like the computer that flies an airplane on autopilot. The plane's autopilot monitors the aircraft's mechanical system and automatically causes it to adapt to changes without the knowledge of the pilot. This is fine for ordinary flying conditions, but I think all of us want to believe that the pilot of our plane is fully conscious and mentally awake and alert and has not turned the entire flight over to the autopilot.
It is even possible to do surgery mindlessly. You may have done a procedure so many times and know it so well that you are like a person driving a car who suddenly realizes that he or she has been driving for 20 minutes without really knowing it. We need our autopilot mindless thinking. Without it we become forever trapped in an analysis paralysis. But we also need our higher consciousness in the form of fully mindful engagement with the world. Toxically successful people are often mindlessly moving through their life and are not fully aware that they are alive until something or someone goes terribly wrong and they have to go off autopilot.
The philosopher Gottfried Leibniz wrote, "At every moment there is in us an infinity of perceptions, unaccompanied by awareness or reflection; that is, of alterations in the soul itself, of which we are unaware." It is this is the kind of almost cataleptic consciousness that characterizes the toxically successful. Healthy success is being able to know when we are living only on mental autopilot and, by doing so, missing out on what make lives worth living.
The toxically successful tend to be hare-brained fast thinkers who have become rigid in their views. They are cynical, quickly evaluative, and often oblivious to context, perspective, possibilities, and creative ways of construing our situation. They are skilled at doing very complex routines while being mentally elsewhere. When one of the surgeons we interviewed defended his mindless way of relating with his wife by saying that he felt that he had "many important things on his mind and the weight of his practice all on his shoulders," she responded, "I'm glad something is on your shoulders, because when it comes to thinking about me, it doesn't seem to be me."
Mindfulness requires an act of will. It is intentionally trying to learn to notice the existence of things and people that we have not seemed to fully notice before. Instead of stress management, it is becoming fully conscious of why we are stressed in the first place. Instead of trying not to be type A, it is trying to become more fully cognizant of why and how we put ourselves in situations in which we pressure and push ourselves to the point of distraction.
ARE YOU CERTAIN YOU'RE RIGHT?
Mindless thinking is misoneistic, meaning being intolerant and even afraid of new ideas related to important issues in life. Mindless people have constantly distracted brains and chronically busy bodies, so ideas like those I am sharing with you can be quickly dismissed or not even fully registered in the consciousness of the toxically successful. They tend to feel certain they are right and in their working, they usually are. Unfortunately, they are unaware that there are many kinds of intelligence and that wise people have many of them that they mindfully match to each situation in their life. Some of the surgeons we interviewed seemed to think no differently in the operating room than they did at home. One kind of intelligence may work well for good cutting but another may be needed for demonstrative caring.
The toxically successful tend to overevaluate their intelligence and consider how they think and see the world as the obviously right way. They are unwilling to take the time to consider thinking in new ways and are so used to autopilot consciousness that—unless they are shocked to awareness by a life crisis—they keep on thinking in the same ways.
Mindless thinkers are what physician Larry Dossey referred to as "right men," who view themselves as lonely brilliant holdouts against a world populated by dopes, dummies, and slow thinkers. He was using a male reference for this way of thinking as it was first presented by science fiction writer A. E. Van Vogt and later popularized by British writer Colin Wilson, but women think this way too.3 However, my own research indicates that it is in fact a way of thinking that tends to be much more characteristic of men. My informal survey of the gender of those who attend alternative or complementary medicine seminars where different ways of thinking about health and healing are presented indicates that female nurses far outnumber male surgeons.
If you will look around this lecture hall, you might notice that some of the right men you know are not here. It has been my experience that those who might most benefit by being challenged by what I have to say are either too busy to come to this talk, prejudge the topic as "soft" and not worthy of their already overwhelmed attention, or have their minds made up and do not want them bothered by "weird" ideas. The problem is, these toxically successful people are often carriers, meaning that they stress and strain others with how they think and act, but their mental autopilot causes them to be oblivious to how aggravating they can be.
No matter what new research they encounter, right men or women constantly extend the goal posts for their criteria for reexamining their way of thinking. The example of the 3 men and the truck illustrates the importance of how we come to view what we do for a living and why and how it influences our general mood. The data are clear that how we think effects our health and immune status, so I hope you will realize that you do not have to have a hole in your head to have an open mind.
ARE WE SQUANDERING OUR GREATEST GIFT?
Where and how we focus our attention is arguably our greatest human gift, and the results of my research on highly successful people as identified by their peers, status, income, and self-reports suggest that it is the content of our consciousness, not the hurriedly scribbled obligations on our calendar, that is an important measure of whether we experience healthy or toxic success. It is not just your surgical schedule but what is on you mind as a surgeon that determines whether whatever success you experience and how you pursue it becomes toxic.
When it comes to the issue of mindfulness, it seems to me that there are 2 unique challenges for surgeons. First, much of your success in your work derives from your ability to focus your attention, work on mindless consciousness autopilot, and work quickly and without hesitation. Most of the surgeons we interviewed prided themselves on their quick thinking and ability to make fast and clear decisions. When it comes to most surgical procedures, pulling up a stool, sitting down, talking story, and taking lots of time to reflect on a more creative way to proceed is probably not the best way to proceed. On the other hand, mindless quick and automatic thinking can also lead to problems.
Most surgeons know that even the most ordinary and common procedure can encounter unexpected problems that require not only hare-brained quick thinking but a mindful and creative tortoise mind. In fact, surgeons tell me that it is often the most common and simple procedures that lead to complications and that their problems seem to come in clusters. One surgeon told me, "I go months doing some pretty complex surgeries and there's not a single problem. Then, for some reason, some simple thing goes wrong and I'm in for a series of complications."
We can only speculate why the "surgical disaster domino effect" occurs if in fact it really does, but I suggest that it may not only be some manifestation of chaos theory, pure randomness, the attraction of the golden mean, or simple spontaneous bad luck that is responsible. Perhaps something is happening to the surgeon's consciousness. Perhaps his or her autopilot is beginning to fail and mindlessness is beginning to take its toll. Perhaps, when things seem to start to go wrong at work, we should also look at home for clues for how we are thinking there and if we may not be becoming too mindless.
The second challenge I suggest is somewhat unique for surgeons and is related to the research on stress. Most studies indicate that the combination of a high degree of responsibility with very little power is a lethal combination when it comes to health and well-being. While many occupations can be characterized by this combination of factors that lead to toxic success, many people assume that surgeons have not only great responsibility but also the power to deal with it. Experienced surgeons know that, particularly outside the operating room itself, their power is nowhere as great as those outside the medical establishment might assume. They are bound by rules, regulations, mountains of paperwork, the conduct of other professionals, and often cannot proceed based on their best thinking and instincts because of obstacles created by nonmedical issues. Because surgeons unquestionably do work that is among the highest level of responsibility but their power seldom matches that level, it might be expected the surgeons would often encounter unique levels of stress.
HAVE YOU LOST YOUR MARVELS?
One of the founders of modern medicine, physician Sir William Osler wrote, "The first step towards success in any occupation is to become interested in it." Interest is mindful. It is never autopilot mentality and involves reflecting on what and why we are doing what we are doing and putting it in a larger meaningful context. Our interviews indicated that toxic success occurs when we approach our work from an exclusively mindless "get it done quickly" perspective. There may be surgeons who have done a procedure so often they can almost do it with their eyes shut, but I doubt that they can continue to develop and learn with a closed mind.
When I was dying of cancer and required several surgical procedures, I always asked my surgeons if they were deeply interested not only in my case but in being a surgeon. I trusted their hands, but I wanted to know what was on their minds and, therefore, ultimately in their hearts. They were often taken aback by my question, and thought the answer must be obvious. Some answered that they would not be doing what they were doing if they were not interested in it, but I have not found that always to be true. Staying interested requires willful acts of attention, remembering, and connecting.
My questioning about interest and my surgeon's state of mind was what we Hawaiians call a mana check. I wanted to know if they still retained their fascination with what they were doing and why.
Just before one of my most life-threatening surgical procedures, I joked with 1 of my surgeons that I wanted to know if he had "lost his marvels." He laughed and said, "Do you mean have I lost my marbles and gone nuts?"
No, I answered, I want to check again to be sure you love doing what you doing and still marvel at being able to do it. I want to be sure the man who is going to open me up is leading an awe-full life, a life full of awe at what he does and the miraculous nature of the human body.
I was trying to determine if he had retained an almost-childish enthrallment with his ability and skills and the privilege of doing such sacred healing work.
ARE YOU WORKING WITH ALOHA?
My 20-year clinical study of some of the most successful people in the world included several surgeons, and I want to share with you today some of the findings from that study that indicate the importance of understanding the difference between the 2 kinds of success we noted in our work. Please remember that I am only sharing some ideas with you that we developed from our study. I am not presenting an entire research protocol. I am here today to get your attention about the nature of success as it relates to your daily life, and that no matter how normal it may seem that you think and behave as you do, normalcy may increasingly be becoming a major health risk factor. As psychologist Carl Jung pointed out, just because millions of people are thinking the same way does not make those people sane.
Because you have come to Hawaii to meet and learn, I invite you to ask yourselves if you are living and working with aloha, a word that means to share (alo) the sacred breath of life (ha). Are you living haole style, a word that refers to being without (ole) breath (ha) by leading the kind of distracted, pressured, disconnected, life in which you seldom take the time to catch your breath or share a breath with others? While you are here in our islands, I hope you will sit down, shut up, take a deep breath, and reflect with someone else about what it might be like to stroll through the corridors of your mind.
At the end of my talk today, I will share 5 principles of healthy success Hawaiian style, a form of excellence in working called po'okela, the Hawaiian word meaning "excellence through mindfully shared values rather than individual objectives." Po'okela is first and foremost mindful working and living characterized by attention not only to your work but also to those who ultimately give purpose and meaning to going to work.
TWO KINDS OF SUCCESS
Our research indicates that there are 2 kinds of success. One is the mindless kind I have been talking about. It leaves you and those who live and work with you feeling constantly pressured, overwhelmed, and with too little time to fully engage in the enjoyment of the simple pleasures of life. It results in a life more stressed than savored. As one of our physician respondents in our study put it,
My clinic schedule leaves me too busy to love and too tired to care. My wife tells me that if I paid as much attention to my patients as I pay to her, I would kill them. She says that we might actually be able to enjoy our life together as much as I seem to enjoy my work if I would only be more alert and mentally with her when I'm home.
Based on our interviews, there is another kind of success that is much healthier and leads to more shared happiness. It is the kind that results in feelings of aloha, meaning being energized by our work and having plenty of mental vitality left over after working for shared contentment, calmness, and a loving connection with the people in our life for whom most us are working in the first place.
Another physician in our study expressed this healthier sense of success by saying,
I'm at least as busy as the other docs in my practice if not more so. I know I have as many patients and difficult cases. The difference between them and me is that I don't seem to feel as pressured as they always are because I know when to say no and when I have to pay attention to where my energy comes from—my wife and family. I take the time to think and not just do and sometimes I commit the ultimate sin of a busy doctor and just sit and do absolutely nothing but think about whatever comes to my mind. I'm not bound by what I call competence competition, the old doctor-keep-doing ethic of being seen as so tremendously talented and in demand that I am exhausted and pushed to the very limit. I'm long over my need to impress anybody with how busy I am and how exhausted it makes me. My mind and my life are my own, and my work is part but far from all of it.
THE TOXIC SUCCESS STUDY
Statements like the previous comments were obtained from extensive interviews conducted over 20 years. In 1975, my clinical team and I at The Problems of Daily Living Clinic at Sinai Hospital, Detroit, Mich, began videotaping interviews with highly successful persons and their families. We conducted thorough medical examinations, Holter monitoring, psychological testing, and videotaped subjects at work, at home, and sometimes when they were driving. Whenever possible, we also interviewed their clients and patients, spouses, and other family members. When we could, we collected dental records and interviewed the persons who worked for and/or with them. I'm proud to say that this work earned us the Rush Gold medal for achievements in preventive psychiatry from the World Congress of Psychiatry.
Over the next almost 25 years including follow-up interviews, we collected a total of 537 complete sets of data. Twenty-nine of these protocols were from physicians; of that group, 17 were surgeons. They had all come to our clinic for psychiatric help, but because ours was the first positive-psychology clinic focusing on maximizing personal strengths and virtues rather than diagnosing and treating problems, none were diagnosed as having psychiatric conditions or prescribed psychotropic medications. In fact, we referred to those who came to us as "clients" rather than "patients." Persons who were in need of more traditional psychiatric care were referred to the traditional outpatient psychiatric program at the hospital.
Of course such a small and highly biased and selected database does not justify statistical conclusions, but the thoroughness of the interviews and the comments from the respondents provide insights and questions I think are worthy of your mindful consideration. They are ideas from and about highly articulate and successful people who admitted to what we came to call toxic success syndrome, a way of thinking characterized by automatic, distractible, mindless, quick, and judgmental thinking that results in disconnection from family and resulted in a sense of languishing–—going through the motions without deeply experienced positive emotions.
I suggest that you take the test we used in our study that is published in my book Toxic Success. 4(pp28-29)
I have abstracted some of the findings from our study of the 29 physicians. They included physicians from a range of specialties and all were board certified and in private practice. Fourteen were professors at 1 of the local medical schools. This subgroup in our study included 21 men and 8 women. The age range was 33 to 61 years (mean age, 47 years). They had trained at medical schools and hospitals throughout the United States; all but 3 were married at the time |
