Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman: Ben Slater is a high school English teacher in San Francisco. He teaches everything from Dostoevsky to Yaa Gyasi to Adrianne Rich, but his favorite class to teach is not an English class at all. It's called examining the good life, based on Socrates' famous quote, the unexamined life is not worth living.

Ben Slater: I actually wanted to just call it the good life, because that was the central philosophical concept, but then the administrator was like, "That just sounds like you're all

just going to be having fun. Let's keep examining in there."

Emily Silverman: What they're examining are different ways of understanding what makes a good life.

Ben Slater: It was a general philosophy class, and I shifted the focus to be what makes for a good life. What makes us happy, how to deal with suffering, uncertainty, and freedom. In the broadest sense, how should you live?

Emily Silverman: The syllabus is broad. They talk about everything from Simone de Beauvoir's death of the serious world.

Ben Slater: I wish I could go back to the serious world, to be honest. I liked having blind faith in something.

Emily Silverman: To the work of Friedrich Nietzsche.

Ben Slater: He's super, super dramatic, and that's what I loved about him. Be the poet of your own life. Here's how you can live a good life while accepting uncertainty. It wasn't just become a monk and meditate for 25 hours a day.

Emily Silverman: All the way back to ancient philosophies like Taoism.

Speaker 2: At that time, I was dealing with a friend who had been really grating on me for a long time. A Daoist would say, "You're in your own boat. You can't ask them to change, you just need to go with the flow."

Emily Silverman: One thing we've noticed about medical training is how much it emphasizes the certainty piece of medicine. Multiple choice tests, for example, don't really prepare students for the reality that some things just can't be known. That's why we were so intrigued by Ben, who's asking his high school students to confront uncertainty head-on. He quotes from Nietzsche to emphasize this embrace of uncertainty.

Ben Slater: Here's the Nietzsche quote. He says, "The secret for harvesting from existence, the greatest fruitfulness and the greatest enjoyment, is to live dangerously. Build your cities on the slopes of Vesuvius, send your ships into uncharted seas."

Emily Silverman: Or, for example, the modern Tibetan Buddhist Pema Chödrön.

Ben Slater: She says, "What keeps us unhappy and stuck in a limited view of reality is our tendency to seek pleasure and avoid pain, to seek security and avoid groundlessness, to seek comfort and avoid discomfort." This is how we keep ourselves enclosed in a cocoon. The mind is always seeking zones of safety, and these zones of safety are continually falling apart. We spend all our energy and waste our lives trying to recreate those zones of safety, which are always falling apart.

Emily Silverman: What both Nietzsche and Pema Chödrön seem to be saying is have courage, step out of the cocoon, let go of the need for absolute safety, and learn to live fully despite the uncertainty. This is a message that we've been hearing from the clinicians and patients who contributed their voices to this series. They're all people trying to figure out how to live well inside the unknown. We notice there seemed to be a spiritual undercurrent coursing beneath these stories. Today, we're talking to two women, both spiritual teachers in the Buddhist tradition, who guide their students toward a more secure relationship to uncertainty, just as Ben is doing with his students. The practice of Buddhism sits at the center of each conversation, but I think uncertainty is actually the fulcrum on which both stories turn. This, of course, is something that the teens in Ben's class know well.

Speaker 3: I really liked the idea that in Zen, Nirvana is realizing that there is no Nirvana because it's being certain in uncertainty. That's what I want to be, I want to be certain in uncertainty. I want to know and be certain in something. I recognize that uncertainty is the way the world works, but I don't want to accept it. That sounds terrible.

Emily Silverman: The venerable Lianghua Su first found her way to meditation and spirituality at the age of 13, when she encountered two books that changed the course of her life. The first was Tom Wolfe's The Electric Kool-Aid Acid Test, a classic of the era about experimentation with psychedelic drugs in the late 1960s. The second, the Bhagavad Gita, one of

the central sacred texts and contexts of Hinduism.

Jill Eggers: It's a spiritual teaching from the Hindu tradition that was about transcending self. This language made more sense to me than the story of Christianity.

Emily Silverman: Jill grew up with a Christian framework. It was the backdrop to how she understood the world, but over time, she followed a deeper instinct, one that led her down

unexpected paths. There were psychedelic experiences in her younger years, yes, but also a life in the arts, a career as a respected painter and professor, and eventually ordination as a Buddhist monk.

We wanted to speak to Jill Eggers, Venerable Lianghua Su is whose ordained Buddhist name, to think about ways that physicians may benefit from engaging with the Buddhist framework beyond the now mainstream trend of mindfulness. What does this spiritual tradition that, as Ben students recognize, is based on a belief in an uncertain world say about how to deal with uncertainty?

Jill Eggers: Buddhism, really, it is the practice of uncertainty. There's just a very fundamental tell to be universal truth in Buddhism that everything depends on everything else, so everything is interdependent, and that everything is impermanent. These two ideas function together, that everything is always subject to change at all times. All of life is uncertainty, and anything, any illusion that we have control, is pretty much an illusion.

The visual of a kaleidoscope would always come to me. Every shape moves and affects everything else that's taking place, and this is ongoing. I started formal Buddhist training when I was 50 years old, and I had been a meditation practitioner my whole life, since 14, but never practiced in a serious way. I was very allergic to the whole idea of any kind of organized religion at all, and then I met this teacher, and something really shifted. I could see that he was a really extraordinary person who really knew what he was doing.

Emily Silverman: Teachers are core to all Buddhist traditions, but they can also be a bit tricky, functioning more as guides than, say, professors. Think of the classic Chinese Zen proverb: a teacher opens the door, but you must enter by yourself. Jill began working with this teacher and training to become a teacher herself, and the experience she found can be

confrontational and challenging.

Jill Eggers: I remember times of thinking, "Maybe I'll move to Ireland or California." I had these bizarre fantasies arising of getting away. The literature says that, in the tradition, if the relationship's really working, you're going to want to run because you're going to be confronted. The teacher functions like a mirror for whatever the student is bringing to the table, for all of your neuroses and all of your projections, and give you clarity about your own experiences, but also pull you back when you're about to fall into the ditch.

That is the teacher's job, very much like your teachers in medical school, to pull the rug out from under you and put you in a situation where you don't know the answer, and maybe you can't, on the spot, figure out the answer, so you carry that around with you. You carry that question. There's even a formal practice for this in Buddhism, where you carry around the question, "What is this?" It's related to the Zen Buddhist tradition of the koan. A koan is like a riddle that can't be answered through the rational mind.

The teacher may give a student a koan, and they may carry this riddle around for weeks or months or even years, until it acts within the psyche to produce the answer, which is not a conceptual understanding, but a realization. When you think you know the answer, you just keep asking the question, so that it's not a rational kind of thing, but it goes a little deeper. Something arises.

Emily Silverman: The typical example of a koan is the question, what is the sound of one hand clapping? There's no logical answer, but it isn't just absurdity. It's an embodiment of uncertainty, inviting you to consider what an answer might be, even if it takes days or years to arrive at one. This is not something physicians excel at. Give us a question and we seek the answer. We're in the business of fixing problems, curing ailments. As we were talking, I found myself wondering how this could be applicable in our workplace.

I love how you're describing Buddhism, not as just a way of seeing the world, but also a very practical way of being in the world. I don't know if you have a lot of doctors and nurses or healthcare workers in your life, but these people are operating in a really difficult environment. It's messy, gory life and death. This is all inside of a container that is growing increasingly dysfunctional.

If you pluck someone out of that environment and walk them out of the bustling emergency room to your car, and you drive down the road to the gorgeous monastery, and suddenly it's quiet, what do you see as potentially being some of the most useful insights or teachings or wisdoms to impart to somebody who is carrying the responsibility of holding other people's lives in their hands in this imperfect environment?

Jill Eggers: The picture you create of taking the clinician out of this high-stress, intense environment, and into the temple, one thing about that is that I think a common cultural view of Buddhist practice, and in fact, a lot of spiritual practice, is that it's an escape. That it's an escape that may be a restorative is how can I fix my personal overwhelm? I think we often, in this culture, dismiss people who are very interested in spirituality or spiritual path, because it seems escapist.

What I think is practical about Buddhism, and what serves this imagined clinician, is that Buddhist training is really about how we train the mind so that we are more effective and whole, and unstressed in our engagement with others. That imagined clinician gets the benefit of stopping to sit in meditation. It's something Buddhists do; we stop. We don't stop in this culture, but if we stop, we make room. We make room for not burying and hiding the stress that we're feeling, but really looking directly at what's going on with us, rather than shifting off balance and hiding things from ourselves.

This making of space gives us a wealth of resilience. It doesn't change that things can be very painful and traumatic and challenging at fast pace in our lives, but we can see that as the matter that's moving along and in the stream, rather than as the hole itself.

Emily Silverman: I think one thing I'm hearing is, instead of taking a bunch of burned out doctors and sending them into the woods for a meditation retreat at a temple, how do you make yourself the temple, or how do you bring the temple into your consciousness and make your consciousness the temple? For people who are trying to learn more about Buddhism or live out Buddhist values, is the goal to be in a constant state of presence and openness, just like you're walking through the hospital and you're like-- Does it come and go, or is the idea that no, actually, if you practice this enough, you live it out in every moment?

Jill Eggers: In my experience and that of everyone I know, the ego always comes back. It's an ongoing, lifelong practice. That's very much what I like about Buddhism, that it's a practice. It's not an ideology. It's about this constant engagement every day, walking with the practice. It doesn't all go away and and it's important to go into, I think, any spiritual practice with eyes wide open about that, that there's not a magical panacea.

I think many people come to Buddhism thinking that they're going to sit in meditation for an hour for a few months, and then they're just going to be always very chill and calm. That's not my experience at all.

Emily Silverman: Just wanted to try something out here where I defend the ego a little bit. For people listening, who are in clinical medicine, who are hearing this about at the end of the day, everything is dependent on everything else, everything is interconnected, there is this oneness that permeates, and that the self is an illusion or a construct, people for whom that feels scary, they don't want to undergo an ego death. They're attached to their Self with a capital S, and some people who might believe that without the ego, we just collapse into puddles of everythingness.

As we think about uncertainty in medicine, and that part of embracing uncertainty is embracing that fluidity and that impermanence, is there also a case to be made for both?

Jill Eggers: Absolutely. It's like when I'm teaching painting, as a painter, I'm driving down the road, and sometimes I'm in traffic. I'm looking at the space maybe between two semi trucks ahead of me, and I'm seeing this beautiful piece of color. My mind wants to shift into the painter's mind and just open to this beautiful visual and go make a painting or something, but if I go there and stay there, I'm going to get into a crash right now.

I can practice awareness training, and I can continue to drink from that well. Our practice teaches us to follow these principles that we have within our day-to-day lives, and they very much involve the presence of the self, the presence of the ego. We don't want to cultivate what one teacher called an idiot, compassion, where we're just, "Ah, everything's all fine." We need to still be strong and present.

We need to push back, we need to be firm, we need to be assertive at times. We need to be present and analytical, and then we need to say, "I take responsibility for that. There is somebody here, and I'm taking responsibility for those decisions and for that outcome." It's not an either-or. It's not a let me plunge over the cliff into the death of self.

Emily Silverman: Instead, it's about making room within the ego and allowing for a more malleable sense of the world.

Jill Eggers: Uncertainty is given as the foundational ground. There is no ground beneath you. The ground is continually shifting underneath your feet, and in Buddhism, we start with that. Everything is impermanent, everything is interdependent, so everything is uncertain. If you start with that, you have less to defend. You're more open to questioning your own motives and your own behaviors. You don't have to protect them from judgment. Over time, with practice of meditation and contemplations, you actually see changes in your brain, and you see changes in your own behavior.

You're cultivating compassion rather than sureness. Then also when, when shit happens, as they say, you're like, "Yes, of course it does. Of course it does." We don't believe that we have rights to a perfect and unchanging everything. There's a lot of unconscious assumption in this culture that are based on this view that things have a greater stability and fixity than they actually do, and so a lot of our discomfort comes from not taking that assumption that this is the way things are going to be.

Emily Silverman: In other words, Buddhism isn't about escaping stress or pressing a reset button. It's not a subtractive process. It's a practice, and for achievement-oriented people like med students and doctors, the idea of daily work toward growth can actually be really compelling. Jill gets this. Her teaching has increasingly brought her into contact with medical and nursing students and faculty.

Jill Eggers: Here's something for your toolbox that's a superpower, and then we pull out the rug later to let you know it's going to involve you sitting quietly for a long time. [laughs] To reframe it as this is going to give you a better way to be effective in your work, and importantly, to your profession, it's a practice that runs absolutely counter to the track you've been running very quickly, very-- in hardcore running mode since you began your training.

Emily Silverman: That tool that Jill's talking about, making space before you act in uncertainty, isn't just for clinicians. It's also useful on the patient side, which brings us to Beth Smith. Beth found her way to Buddhism along a different path. She was born three months premature in a small town in Tennessee with cerebral palsy, and treatment for CP was different in the 1950s

Beth Smith: I think it's still the experience with children with CP, that there's a lot of intervention that happens early on. I had a lot of surgery when I was little to try to lengthen muscles and lengthen ligaments, but I learned to walk at nine with braces and crutches. Once I became an adult, it was much more complex for doctors to figure out what to do with me, how to help.

Emily Silverman: She'd spent her childhood working with doctors to fix her CP, and now, as an adult, she still didn't fit the mold of normal. She'd gone through all these surgeries, and it was unclear to her doctors, to her family, and even to herself, what the next steps in her treatment should be.

Beth Smith: I grew up in a pretty traditional Christian family, and actually the church community we grew up in was lovely and wonderful and loving, and got our family through a lot of the surgeries, a lot of the family struggles. However, as a young adult, I started to have trouble with the us and them paradigm of it. Not all Christian traditions are like this, but for many churches, we're right and everybody else is wrong, and the other party is like, if you're on the side of right and you do the right thing, then God is supposed to make everything okay. Those boxes weren't working.

Uncertainty is very uncomfortable for everybody, for the patient, for the doctor, for the family, and what I became accustomed to as a kid is trying to find someone to blame. I really felt like there wasn't any uncertainty. It was my fault. There were years of my childhood where I thought if I just lost enough weight and did my exercises like I'm supposed to, I won't have CP anymore. That's how I dealt with uncertainty then.

You know how around children, people are saying when you grow up, blah, blah, blah, blah? No one said that to me or to my family. I needed someone to say when you grow up and have a job, or when you grow up and have an apartment, or when you grow up and someone falls in love with you. I feel-- Even I say that now out loud, yes, part of me really long to hear that, that I had possibilities.

Emily Silverman: Her doctor warned her that if she ever started using a wheelchair, she would never walk again, so Beth avoided the wheelchair at all costs, which put severe pressure on her joints. Eventually, that same doctor, weeks later, when Beth saw him for all the joint pain, asked why Beth was so hell bent on not using a wheelchair. She was furious. He was the one who told her to keep walking in the first place, but she accepted that she would have to give up walking because the pain was just too great.

Beth Smith: I just saw myself as an ambulatory person, and this felt like such a huge loss. I made a decision. I had an epiphany: if I'm going to use a wheelchair, I don't want to live here. I grew up in Nashville. There's great things about Nashville in the south, and I missed some things, but it wasn't physically and psychologically accessible back then. It was pretty common for people to say, "Bless your heart, you poor thing," and it was a patronizing place. I said, "I want to live somewhere else if I'm going to use a wheelchair all the time."

I thought about all these different cities across the country, and then I went, "Oh, my God, I could go to Berkeley." I looked for a job long distance, and came to the birthplace of the disability rights movement.

Emily Silverman: It was here in Berkeley that she encountered Buddhism, which changed everything.

Beth Smith: The Dalai Lama says, "My religion is kindness," which I was totally attracted to. Buddhism is a practice more than a belief system, more than a religion.

Emily Silverman: It was also the way Buddhism handled uncertainty that hooked her.

Beth Smith: Uncertainty happens. It happens to everybody. Uncertainty causes suffering. Uncertainty can cause suffering. Buddhism offers a way to sit with hard things that aren't about fixing itch, that aren't about striving to be better, that aren't about treating God like a vending machine or something.

Emily Silverman: She found a way of seeing her life as something already whole, rather than something that needed repairing.

Beth Smith: Wait a second, the most powerful thing here is compassion. For me to give that to myself? I'm the source, rather than some being that I'm trying to access, some way who thinks I'm a sinner? It was like a itch being scratched.

Emily Silverman: This new perspective immediately changed the way she conceived of her cerebral palsy.

Beth Smith: It's the social model of disability versus the medical model. It lends itself to uncertainty and blame if you're seeing your patient as someone who needs to be fixed, and what about we change the conditions in the world to make it easier for me to do the things I want to do? That's a social model. Why don't we make the world more disability friendly, rather than focusing on we have to change this flaw in this person?

Emily Silverman: This paradigm shift for Beth was born from her time practicing Buddhism. I think this is worth underlining. We often see sitting in meditation as opting out of action. After all, how much can you really get done just sitting there? For Beth, the practice of sitting brought about a new clarity. She realized that the medical expectations her doctors had for her were coming into conflict with her own dreams and desires.

Beth Smith: It's about having expectations for someone that aren't just medical. I don't want to just not have painful knees. I don't want to have painful knees because I want to have a life. I want to be in love. I want to go to school. I want to learn. I want to have a life.

Emily Silverman: She brought this perspective to her career as a social worker, supervising and training psychotherapists, which she did for almost 30 years. Not only that, Beth also began leading meditation groups for people living with disabilities, limitations, differences, and chronic illnesses, which she still does today.

Beth Smith: The work I've done is more about supporting people's wholeness and the reality of people's wholeness. We call it a non-pathologizing approach to therapy, where people get a chance to discover for themselves who they are and who they are is not broken. It might be hurting, but it's not-- we're not flawed people. Also, the other reality that I come to terms with is we all have bodies. We all have bodies that don't do exactly what we wish they could do. We all have bodies that hurt sometimes.

There are people that have certain conditions that make us more aware, or certain conditions that look bigger, but we all have these bodies that are very, very different. If we all got everything we needed, would those be deficits? Would those conditions be deficits? I'm not sure. One of the things I say to the group when it's my turn to teach every time is, "It's so important that you're here. If you weren't here, this group would not be as good." I say that more eloquently to them. The other thing disabled people are taught is, not only are we less able, but we're a drain, we're a burden.

Sometimes one of the things I end up feeling and saying to myself in meditation, and I think it's valuable for everyone, is, it's so important that you are born. It's such a good thing that you are born, such a good thing that you're on this planet right now. I'm like, "Oh my God, right now?" Because it's so hard and scary and are made to feel so powerless, but our presence in the world makes a huge difference.

Emily Silverman: Today, we're going to close this episode a little differently than usual. We're going to close with a meditation from Jill Eggers, the venerable Lianghua Su. It's relatively short for those of us who are new to meditation, around six minutes long. Enjoy, and thanks for listening.

Jill Eggers: This is a guided meditation from the Buddhist tradition on impermanence. When we practice seeing the impermanent, constantly changing nature of things, we develop a friendly relationship with uncertainty. We can become more flexible, open, and aware of the present. First, establish a comfortable posture. This can be in your chair or a cushion, whatever works. Close your eyes or let them rest gently on the floor in front of you.

Let's take three deep cleansing breaths. Feel the breath coming in and going deep through your center, exhale with a deep feeling of release.

[pause 00:30:58]

Jill Eggers: Now, let's sit for a moment in the empty space of our mind. See if you can visualize yourself in the center of a great sphere of light. It's so peaceful here, you can just relax. You're just relaxed and can be supported in this field of light. [silence] Let's examine and penetrate the impermanent nature of all you see. Let's examine and penetrate the creation and disintegration of a second of time.

Watch the second of time arise and pass away. Now let's examine and penetrate the creation and disintegration of a midget of time, those 60 seconds of time that arise and pass away.

[pause 00:32:27]

Jill Eggers: Consider an hour, a day, a month, how vast a number of creations and disintegrations of seconds there are. Not one of these moments will ever exist again. [silence] Time is impermanent. What arises and passes away is uncertain. Let's consider the creation and disintegration of the seasons. How things become in the spring, how things grow and thrive in the summer. How things decline in the fall, how things die in the winter.

When you consider, life is like a second of time, a minute, an hour, a year. Life is like the seasons, where we pass from birth through life to decline and death. Life, too, is impermanent, uncertain. Words are created and disintegrate, just like this. Actions are created and disintegrate, just like this. Relationships are created and disintegrate just like this.

The creation and disintegration of all things is a universal truth. All things are impermanent. Everything is subject to creation and disintegration. Nothing is exempt from this, not even yourself.

Knowing the impermanent nature of all that is, what is there for me to cling to or reject? Just as I cannot take hold of a reflection in a mirror, or pluck the moon from its reflection in water, there is nothing I can hold on to, not even myself. Take three deep cleansing breaths. [inhales and exhales] When you're ready, move your body a bit, open your eyes, and come back to the room.

[music]

Emily Silverman: Thanks for listening to The Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, The Nocturnists' head of story development, Molly Rose-Williams, producer and editor, Sam Osborn, and our uncertainty correspondent, Alexa Miller of ArtsPractica. Our student producers are Claire Nimura and Celine Everett. Special thanks to Maggie Jackson and Paul Han. Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Ashton Spencer, and additional music came from Blue Dot sessions.

Artwork for Uncertainty in Medicine was created by Eleni Debo, who is represented by Folio Illustration and animation agency. The Nocturnists Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation, and the Josiah Macy Jr Foundation. The Nocturnists' title sponsor is the California Medical Association, a physician-led organization that works to keep the doctor-patient relationship at the heart of medicine. To learn more, visit cmadocs.org. The Nocturnists is also made possible by support from listeners like you.

In fact, we recently moved over to Substack, which makes it easier than ever to support our work directly. By joining us for a monthly or annual membership, you'll become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com. If you enjoy this episode, please share with a friend or colleague, post on social media, and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman. See you next week.