To become an expert in your field, you have to take the worst possible outcome in your profession and imagine it as inevitable; indeed, imagine it to have already occurred. If you do that, the fear of such an outcome can no longer touch you. Your mind remains clear and nimble.
I am an anesthesiologist, and I learned this lesson one day when assigned to care for a very overweight seven-year-old boy needing a tonsillectomy. I hadn’t taken care of a child in months, and I was unusually nervous. The physiology of children differs from that of adults. The heart rates of very young children are faster. Children turn blue more quickly. Special attention must be paid to drug dosages and the size of breathing tubes. In the holding area, I put on a happy face as I greeted the boy and his mother. I handed the boy one of the inflated balloons our department keeps to cheer up children. The boy grabbed it and looked at me without the slightest interest, as if knowing beforehand that I would have nothing sincere to say. While taking his medical history, I laughed at every funny word he uttered, seeking to ingratiate myself with him and his mother—and to hide my anxiety.
I left them to go set up the operating room. Such rooms exist in a kind of permanent winter. The walls, the sheets, and the cotton balls—all are white, giving the feel of new-fallen snow. When the nurse opened up an instrument pack, the sound was of twigs in a cold forest cracking underfoot. I shivered and coughed; my hands were freezing. For a moment I forgot how nervous I was.
Then the mother entered the room along with her son, tears streaming down his red, blotchy cheeks, and I was reminded of what I feared. Because of the boy’s large size, I thought it safer to put him to sleep not with gas, which is the usual modality in children, but with a needle. The nurse tried to comfort him while I prepared to place the intravenous, but the boy protested, trying to jump down from the operating table.
“Just a tiny stick,” I said. “Really, it doesn’t hurt.”
“Then stick yourself and let me see!” cried the boy.
Having steered myself into a trap, I had no choice but to prick myself in the forearm and draw blood. Satisfied, the boy calmed down, but by the time I had gotten a fresh needle from the drawer, he began to scream again. As I moved closer, he lunged at the nurse’s arm with his mouth and clamped down. “He bit me!” screamed the nurse. “Damn you, Ron!” she yelled at me. “Why didn’t you give him some nitrous oxide to put the IV in?” I should have, but fear had crowded out my reason.
I decided to revert to the standard method of breathing him to sleep with anesthetic gas. Placing the mask on the boy’s face, I pointed to the anesthesia bag attached to the machine. “Try blowing up the bag, just like at a birthday party,” I told him. “See if you can make it pop!” But the boy kept pushing the mask away. The boy’s screams kept coming, flying over one another, while his mother could barely repress her own sobs. By the time the boy eventually fell asleep, I was left to wonder who hated me the most—the nurse, the mother, or the boy.
I inserted a breathing tube, and the surgeon began the operation. Somehow things were too quiet. I grew jumpy. My imagination fixated on disastrous images of the worst possible outcomes. The boy might suffer an asthma attack, a hemorrhage, or a cardiac arrest, I thought, and the only thing standing between him and death was me, an anxious doctor. I wanted to be done with this case, but the minutes crawled slowly, tormenting me. I listened for an alarm to go off on one of my monitors. When the boy’s blood pressure declined at one point, I sprung from my chair, as though to hurry off somewhere, and checked his pulse and pallor, only to discover that the nurse had been accidentally leaning against the blood pressure cuff. My eyes went back to staring at the monitors. I overanalyzed the numbers on them, found hidden meaning in the slightest aberration, and repeatedly adjusted the anesthetic dose. At one point, I heard a whistle. I feared the boy might be wheezing, but the sound was coming from my own nose.
About 20 minutes into the operation, a problem arose. The boy’s breathing grew shallow, and his oxygen level declined. I tried forcing air into his lungs, but it proved difficult to do so. I did not know why. My thoughts darkened. The boy might die! I tried to figure out what the problem was, but other thoughts seized control of my mind. I had never lost a patient. Were these the last moments of my good reputation as a doctor? My mind raced. Today, for the last time, people would treat me with respect; today, for the last time, my colleagues would shake my hand. Everyone who smiled at me today would avoid my gaze tomorrow, knowing that a child had died under my care.
The boy’s oxygen level kept falling. His pallor became gray. Tomorrow, I imagined, he will be lying in some morgue among other bodies, his skin white and blue. His hands will no longer be folded on his stomach; they will be thrown out sideways over a gurney. His leaden gaze will be fixed. Only in one single spot, in his arm, where I had finally placed an intravenous, will a drop of blood testify to his having recently been alive.
I looked around to see whether others were as frightened and distracted as I was. They seemed oblivious and contented. I needed to warn them, but my dry lips were cracked and it was hard to speak. I shouted in a high falsetto, “We have an emergency! We have an emergency! I think the boy is having an asthma attack, or a mucous plug has blocked the tube, or …” The surgeon just looked at me; then, without breaking stride, he loosened the brace that held the child’s breathing tube in place while he operated. With the tube now clear, the boy’s breathing and oxygen levels immediately returned to normal. The surgeon then resumed telling the nurse about a new addition he had put on his house.
I felt ridiculous.
The case that I had imagined would draw a line across my existence, forever separating my past from my future, ended 10 minutes later with the surgeon giving the nurse the phone number for his builder. Exhausted, I took the boy to the recovery room, then wandered into a corridor that felt more like a dark, menacing alley. Peril and death were everywhere, I thought.
Another anesthesiologist came over. He and I had the same years of experience, and I told him about my near miss. “Scary, no?” I asked. He looked at me with surprise.
“Listen, one of your patients is going to die eventually,” he said. “So just expect it.”
His nonchalant attitude shocked me. This doctor has no heart, I thought. All during my case I had thought, There, ahead, is the brink—there, the black abyss. Maybe the dead child’s family would come after me. Maybe I would be sued. Maybe my name would appear in the newspaper. Maybe everyone would say awful things about me. Maybe I would lose my license. Maybe, maybe … Then the wisdom of my colleague’s indifference dawned on me. He practiced medicine as if a patient of his had already died, as if he had already suffered the consequences and had come to terms with them. I, however, lived in fear of such an event, imagining the worst-case scenario and trying to keep it at a distance.
The lesson I learned that day was an old one. Japanese samurai counseled the same outlook centuries ago. “The way of the warrior is the resolute acceptance of death,” wrote Miyamoto Musashi in The Book of the Five Rings (1645). The warrior must take the worst outcome in soldiery—death—and imagine it as inevitable, indeed, imagine it to have already occurred. Once a warrior has done so, the fear of death can no longer touch him. Having befriended death, the warrior is not distracted by thoughts of self-preservation during combat and so becomes a better fighter.
Likewise, in Hagakure, or “Hidden Leaves,” written in the early 18th century, Yamamoto Tsunetomo tells samurai to follow the way of the warrior, which is death. This means that when faced with a life-or-death situation, “there is only the quick choice of death.” The desire to live only hobbles the warrior. Tsunetomo writes, “If by setting one’s heart right every morning and evening, one is able to live as though his body were already dead, he gains freedom in the Way. His whole life will be without blame, and he will succeed in his calling.”
Fear of death—whether of your own or of the people in your care—binds, smothers, and strangles the mind. For fear of death strives to be an object of contemplation; otherwise it would not be felt at all. People who fear death anticipate it and wait for it. They relive the drama of the impending death, over and over again. Each detail is horrifyingly re-experienced; in the imaginations of people who fear death, the dead never stop dying. Fear of death gives death an entire past and future while nullifying the present in which decisions must be made.
Recently, I met two veterans who personify the samurai ethos. The first, who served as a squad leader in Iraq, told me that he had expected to die in battle. No longer dogged by fear, he found that his senses were heightened, as was his awareness of his environment, which drew him further into the moment, thus enabling good decisions that saved both him and his comrades. By dwelling in the moment, he avoided sparring with shadows; rather than becoming preoccupied with imaginary dangers, he fought real ones. His mind dwelled less on the abstract proposition of dying and more on the well-defined perils around him.
The other veteran had served as a bomb-disposal technician. He went on missions assuming he wouldn’t come back, he explained, which made it easier for him to do his job. Fear causes an expert to fixate on one thing to the exclusion of everything else, he said, which is dangerous. A bomb-disposal technician might fixate on the wires but then overlook the bomb’s battery, or the bombmaker’s purpose in positioning the bomb here and not there. Big mistake.
In a letter to a swordsman, a 17th-century Zen priest named Takuan described the clarity of mind enjoyed by the warrior who no longer fears death. A swordsman who is afraid focuses his mind on his opponent’s sword, or on cutting his opponent, or on the fear of being cut, he wrote. Such fear causes the mind to grow fixated on one thing, making defeat inevitable. Takuan wrote that the mind must be placed nowhere; that is, the mind must be spread throughout the entire body, concentrating on nothing in particular. That way, the mind will serve whatever aspect of the situation needs immediate attention. If the mind is placed nowhere, it will be everywhere.
The only way to achieve this state of mind is to not be afraid. One must have stared into the abyss, seen the worst, and shrugged; one must have been thrown into a cage with a beast and come out alive. The warrior dies, the doctor loses a patient, the pilot crashes, the gambler loses her money, the chef burns the dessert. To think straight during a crisis, aspiring experts must control their fear. To do so, they must adopt the attitude of condemned people. They must not fear the worst; on the contrary, they must live in almost contented expectation of it.
There in the hospital corridor, I took to heart my colleague’s nonchalance and underwent my own thought experiment. I looked straight ahead, seeing no one. I envisioned a barren expanse, with an empty grave open before me, waiting to swallow up my happiness. I imagined I had just lost my first patient. In my own way, I had become a corpse, too, I thought. Yet I was a galvanized corpse that was imperturbable. It had always been my fate to lose a patient, I told myself. There had never been any reason to resist. While I was thinking along these lines, my very soul seemed to slip down into a bottomless black pit. I imagined losing my good reputation. I thought of that reputation with pleasure, with affection, with regret—as you might think of a dead person you had once loved. Ah! Well! And at that moment I felt sober and resigned, as if I had lost my youth but gained peace of mind. I felt as if my imagination had extinguished hope and fear alike in deference to the inevitable. Patients die. A patient of mine had died, I imagined. At that moment, existence in the hospital lost its special intensity. I felt free. It was as if dancing balances in my mind were being brought to rest. Something within me had been quieted.
