Mindfulness

I was approached by a good friend to contribute an article to the Residency e-letter awhile back, with instructions to write anything I wanted provided it was written from my own perspective; no Residency propaganda, no fiction etc. He said, "Since you always go out so much, share with us some of your secret places to relax in Singapore lah!" (Well, would not be that much of a secret if shared, right!).

Instead, I scribbled notes for an article on pillow shopping and the different types of pillows available for different sleeping styles, be it back, side or front sleeper. That rode on a recent splurge on a latex pillow, which cured an unbearable stiff neck and painful para-scapular trigger points. But, as always, life is what happens when you’re too busy planning. Before I could sit down proper to write that, events at work hurled me into a whirlwind of disillusionment and jadedness, too deeply entrenched in an imperfect system with little power to change it.

Started writing furiously as an outlet, lamenting and complaining, pointing fingers, fault-finding to justify the transformation from a doe-eyed teenager who wanted to do some good in this world to a fatigued, unmotivated doctor in existential crisis.

Since the beginning of civilisation, people turn to divine powers and beings in times of need. It seems only natural. When something happens seemingly beyond your power and control, then it is time to give up, plead and bargain for help, for a miracle. But I could not reconcile with that. I have fallen and experienced enough disappointments and hopelessness, to understand that no one is going to be able to help, not even a God, unless I help myself first.

Am I too proud? Too obstinate? Too blind to surrender and succumb to divinity? I do not know.

All I know is, all the healing that has been able to take place through the difficult times, came from support of family and friends, and also, most importantly mindfulness and meditation.

Mindfulness is to me, what possibly prayers are to the religious. The concept of Mindfulness has its roots in Buddhist teachings, specifically Zen Buddhism, but I do not consider myself a Buddhist. Foremostly, understand this, the practice of mindfulness, and its cousin, meditation is non-religious in nature. In fact, I believe it is a helpful adjunct to whichever religion you practise.

Let's talk about meditation first.

My story began in final year of medical school, that crucial stage of cramming, being a saturated fact-absorbing human sponge wrecked with trepidation and feelings of inadequacies. Not unlike many others, experienced insomnia and resorted to many methods to sleep. Sleep just would not come easy, when voices #1, #2 and #3 chant.

'Sleep sleep sleep!' but voice #4 wanted to know the top 20 differentials for chest pain, and voice #5 was off in lala-land, wondering along the absurd lines of whether it was possible to intubate a giraffe. The body ached for rest but the mind would not allow. The more sleep does not come, the more anxiety builds up as the seconds count down to the morning alarm, the more sleep does not come - some vicious positive feedback loop. Ultimately, the body broke down.

I was lucky enough to have 2 batchmates who were into meditation and took me to classes then. The classroom was actually the air conditioned living room of a terrace, owned by a Buddhist organisation but open to all who wished to learn meditation, with no hard selling of Buddhism. A practising senior doctor in public service, happened to be there and gave a short tutorial on the basics, which I still do use even up till today. There are many forms of meditation, the most common being breath meditation.

For beginners, the best way to begin is perhaps with a group, to grow discipline and patience. The setting has to be optimal as well, cool temperature, minimal ambient noise, 2 hours after a meal, comfortable clothes. The most common posture is sitting cross-legged in a full lotus or half lotus position, sitting on a flat cushion with just the buttocks touching, straight back but not stiff, hands one on top of another, palms facing skyward with the thumbs gently touching. With time, it can also be practised lying down in bed, sitting on a mrt train or on a long haul flight.

The crux is in the breath. The breath becomes a link between the surrounding and the body with its consciousness. Concentrate on a spot in space, about 5mm away from the nostril and above the philtrum, like a gate that monitors each breath in and out. Do not aim to control the breath, rather learn to be an observer.

Over time, I learnt to recognise when my body and mind was stressed just by observing the tempo and depth of the breaths. Most of the time, it smoothens out naturally from short shallow breaths to what I'd like to recognise as my own natural breaths - effortless, calm breaths with somewhat prolonged expiration and a pause after, before the next intake of breath. But truth be told, it is not all that easy as it sounds. Sometimes, it takes as long as more than an hour to reach that stage, sometimes it does not occur at all. We were bred in a society that cultivates and rewards productivity, our minds are not used to concentrating on just one thing - the breath, something seemingly always taken for granted at that. Thought invasions occur inevitably, I fought these initially, trying to go back to just concentrating on the breath, but failed. The trick is never to fight, but to recognise these thought disruptions and go "Ah right. So you've been sitting on my mind, I know you now, but I’m letting you go for now" and return to the breath - acknowledge them, do not fight them.

It has also been through these sessions that I come to realise some of the issues which were taking up space in the subconsciousness, banished and left oppressed there. The deepest stage of meditation I've ever been to, was a sensation of floating in dark space, with no bodily sensation, ie: no proprioception (even as youre sitting somewhere reading this, your senses do not go to sleep, you still feel your feet in your shoes on the ground, your back against the chair etc). To lose proprioception, gave that feeling of floating; but it does take time and practise to get there. Meditation is like a muscle, the more it is trained, the easier it becomes to use. The feeling of calmness blankets after, allowing the healing to begin - knowing that life goes on, rationalizing the impermanence of pain and hurt, that suffering is inevitable to experience that which is life; both the ups and downs.

Mindfulness; a practise if mastered, allows us to restore ourselves. We consider it a miracle if one can walk on water or in thin air, but I consider it a miracle just being able to walk on earth. Especially for us, in our profession, having seen patients struggle with something as simple as walking.

Mindfulness, is the awareness of life; in this moment here and now. In my Housemanship, I experienced this most acutely. Armed with a checklist of changes, I would rush from patient to patient, checking off the tickboxes quickly so I could be done before lunch, then settle down in the MO room after lunch to rest and consolidate before exits, then rush home to rest before the whole cycle repeats again; that daily grind. In those moments of rushing from here to there, I was not alive; that not only compromised my patient care as well, because I could not slow down enough to listen to them, to talk to them but also led me into a zombiefied, machine mode which wore me down. If we do not have mindfulness, we would not appreciate and enjoy the here and now. Being mindful does not equate to being slow and inefficient (unacceptable for an Emergency Medicine Resident especially.), it just means being aware as we go about our activities; being aware of that look of fear on that ah-ma's face as you prepare to poke her, so you can offer a kind word or two.

In a broader sense, mindfulness can be as simple as being aware of our own sensations, such as tasting the food in our mouths instead of being distracted with the phone, to being as complex as sitting down with awful feelings of hurt, fear and inadequacies, understanding how each emotion plays out within our bodies (how does hurt affect your breathing? how does fear affect your abdomen? cold sinking feeling?) As I read Rudyard Kipling's "If" with a line of "to wait but not be tired by waiting", I wondered whether that in itself, is a reflection of his mindfulness. We keep hoping and looking forward to a better time in the future.

As a JC student, I thought I would be happy as a medical student striving to fulfill my dream.

As a medical student, I thought I would be happy as a doctor, living my dream.

As a HO, I thought I'd be happier as an MO.

Now as an MO, I've only realised that we keep searching for happiness in the future, but really all we have is the here and now.

Breath meditation links back to wakeful mindfulness for me, because when my thoughts are dispersed by barrages of intrusive distractions, I use the breath as a reminder. As I breath in and out, as does my focus returns. I find mindfulness the easiest to practise and cultivate in a natural setting, which explains a deep-seated love for trekking and mountain cimbing holidays during annual leave.

The latest was a 5 day hike on the Milford Trek in New Zealand's South Island this year. As we trekked the alpine forest and scaled Mckinnon's pass, the senses came alive. Feeling the uneven earth or gravel paths through the hiking shoes beneath; Smelling the scent of eucalyptus, damp earth; Listening to the leaves of the canopy rustle in the wind above, the birds chirping in the distance and the rushing river to the right; Seeing the majesty of them tall trees giving way to alpine shrubbery as we climb higher, then the view of distant ridges from the top with blue skies that stretched to the horizon.

Mindfulness, step by step, breath by breath.

Recently, hard times came down upon again. This time round, realised how weak the meditation muscle was still, suffice to say, dwelled in the depths longer than I had hoped to. Slowly beginning to practise more consistently now, to learn again.

As I sit here, in my aeroplane seat typing this, my body aches for the good treks and hikes to come this trip. As I do, I still hope to grow a stronger layer of resilience, but still never losing that doe-eyed innocence and passion to do some good for patients in a system which has profound ability to grind us down.