Calling Doctor Upaya

Jerome Groopman, professor of medicine at Harvard Medical School and staff writer for The New Yorker, has recently produced a book called “How Doctors Think,” a series of essays that explore the rational and irrational factors that influence medical decision-making. Although the book explains how doctors can draw the wrong conclusion, and why that same doctor might also come up with a brilliant diagnosis that has eluded his peers, it also illuminates how the mind works in general.

Like much of life, uncertainty hovers over the practice of medicine. Most medical mistakes are not due to technical screw-ups, like reading an X-ray backward or inadequate medical knowledge. The majority of problems are rooted in flawed thinking that can set off what Dr. Groopman calls “a cascade of cognitive errors.” Emotions complicate the process even further, feelings that, Dr. Groopman writes, “we do not readily admit to and often don’t even recognize.”

In medical school, doctors are taught to recognize symptoms and then propose hypotheses as to their cause, ruling them out one by one until the correct answer, and of course treatment, emerges. In the real world, under the pressure of life-and-death emergencies, this model goes out the window, and something called pattern recognition takes over.

Along the way, subtle influences can skew the decision. Dr. Groopman, using case studies, illustrates common logical fallacies like “availability” and "confirmation bias." Availability is the tendency to reach for the plausible explanation nearest to hand and ignore competing theories. Confirmation bias occurs when doctors selectively highlight evidence that supports what they expect to find. Then there’s commission bias, the urge to act rather than do nothing, even when nothing is preferable.

These are similar to the Buddha's teachings of the mechanics of the mind. I have previously spoken here about sanjna, the knowledge that comes from combination, often translated as "perception." The Buddha taught that our perception combines our sensations, what we see, hear, think, and so on, with sanskara, a term variously translated as "mental formations," "impulse," or "predisposition." Red Pine translated sanskara as "memory," not memory in the typical sense such as nostalgia, but a specific form of memory which is the source of a never-ending supply of conceptual formations. "What this term basically refers to is our karmic genome," Red Pine writes, "the repository of all that we have previously intended, whether expressed in the form of words, deeds, or thoughts. Thus, samskara embraces all the ways we have dealt with what we have experienced in the past and that are available to us as ways to deal with what we find in the present."

“The mind acts like a magnet, pulling in the cues from all directions,” Dr. Groopman writes. In the emergency room, a doctor encounters a scruffy patient in insulin shock. The doctor instantly and semiconsciously assimilates the relevant data (semi-comatose male, unshaven and poorly dressed), compares it with past cases (the hospital takes in a large number of alcoholics) and misidentifies the patient as a drunk. Sensation (vedana) is filtered through samskara to form the doctor's perception (sanjna).

The early Buddhists (who were nothing if not list makers), identified 52 kinds of habitual behavior patterns, such as intelligence, belief, shame, confidence, indolence, pride, anger, envy, sloth, repentance and doubt, anything that might provide us with a template from the past with which to perceive and deal with the world as we experience it in the present.

“How a doctor thinks can first be discerned by how he speaks and how he listens,” Dr. Groopman writes, noting that studies have shown that physicians, on average, interrupt patients less than 18 seconds after they have begun telling their story.

A woman in her 30s, who had seen 30 doctors over a period of 15 years for a condition that the experts had decided was anorexia and bulimia, pays a last-chance visit to a new doctor, who pushes aside the thick dossier on his desk and listens closely as she retells her story from the beginning. A small detail here, a nuance there, leads the doctor to suspect that there is something other than anorexia causing this patient to reject food, and he is right. It turns out she suffers from celiac disease, an allergy to gluten.

I have seen this same dynamic at work with spiritual teachers. A student expresses his or her concerns, fear or desire, but the teacher catches a certain "buzz word" early on and starts lecturing the student about, say, spiritual materialism, when the student was actually plagued by insidious doubt. Or the teacher, having discussed spiritual materialism earlier, simply picks up the last conversation where it left off with a different individual, whether it's relevant of not. And then the student encounters a wise teacher, who listens, and although various samskaras present themselves, does not instinctively leap to the first one available.

Upaya is the employment of skillful means to help bring others to enlightenment. A Zen adept is considered a Master when he is able to reliably employ upaya. I argue that upaya is the ability to listen, and to resist the desire for sanjna perception to utilize a samskara template inappropriate for the situation at hand.

I'm sure if we all look closely at our behaviors in a score of different situations, we would see the same dynamics at work as Dr. Groopman discusses so eloquently.