Inviting Everything into the Room

As a young oncologist, Anthony Back turned to Buddhism as a practical way of processing the suffering and death he encountered each day. “I came to Buddhism out of a sense of trying to survive,” he told Tricycle’s editor-in-chief, James Shaheen, and meditation teacher Sharon Salzberg. Over the years, his practice has become an essential support to his work in accompanying patients as they navigate illness and death, and it has radically transformed his understanding of what it means to provide care.

In a recent episode of Life As It Is, Shaheen and Salzberg sat down with Back to discuss how he integrates his Buddhist practice into his work as a physician, how he deals with burnout and moral injury, and what James Joyce and Virginia Woolf have taught him about paying attention. Read an excerpt from their conversation below, and then listen to the full episode.

James Shaheen (JS): You’re currently the co-director of the University of Washington Center for Excellence in Palliative Care and a professor of oncology and medicine, and you’re also a practicing Zen Buddhist. How did you first come to Buddhism?

Anthony Back (AB): I came to Buddhism out of a sense of trying to survive. I was a young oncologist, and I was feeling overwhelmed by the amount of suffering and death that I was dealing with. I thought, “How will I make a career of this? How will I keep doing this day in and day out?” That led me first to mindfulness and then to Roshi Joan Halifax at Upaya Zen Center.

Sharon Salzberg (SS): You currently work in palliative care, and so much of palliative care seems linked to honest communication about illness and death. How has your Buddhist practice influenced your ability to have these conversations?

AB: What my practice has enabled me to do is work at a layer that is below the words. Of course, there’s a lot of teaching about what words to use and what words help you come across as empathic. But what my practice has taught me is that my stillness can make space for whatever the other person is experiencing and that my ability to be with it and not push it away can create a field for deeper communication. I don’t think I would’ve learned that any other way. The priority in my world is not about stillness. It’s about efficiency. And it really took taking myself out of the hospital to learn to practice that kind of stillness inside and outside to be able to sit with people.

SS: When we’re confronted with suffering, it can be so tempting to look away or to try to avoid it at all costs. How have you seen this avoidance or resistance to suffering play out in the medical field, and how do you train providers to be able to talk openly about suffering?

AB: In the medical field, the usual reaction to suffering is that we should be able to do something about it, and if we can’t treat it now, we need to find new treatments, and so we need to do more research. There is something really good in all of that—that is how medical practice improves. And yet if we don’t pause to be with that suffering and to witness it and to be present with the person, then something gets missed.

It is a constant struggle to make the time to be still in the midst of these busy practices. And because it’s not reinforced by the system, because it’s not reimbursed or formally taught, very often mindfulness gets the label of being just another technique. Of course, what you learn after years of practice is that it is a way that you bring yourself into everything. It’s not just something that you apply at the moment; it is a way you are present in the moment. It is the ground that you’re coming from.

The more that we can both be present with everything, the more there is really potential for a kind of healing.

JS: You’ve talked about the sense of inadequacy and powerlessness you can feel in the face of a patient’s suffering. Has your Zen practice shifted your relationship to this powerlessness, and more broadly, has it changed your understanding of what it means to provide care?

AB: First, I would say that Zen practice has radically shifted my sense of what powerlessness means in the sense that I appreciate all the things that medical technologies can do, and yet I don’t use them with the same kind of expectation that I will be able to have power over another person’s body. There are things going on biologically that are so complicated that we’ll never be able to completely understand them. And so coming at it that way gives me a kind of humility about the situation, which changes my expectations about what will happen.

The other thing that has shifted in my understanding is that there’s a technical aspect to the care that I provide, but then there is also a more personal aspect, which is more than just emotional care. It is the care of being present. It is the care of witnessing. It is the care of sharing space with another human being. And I think that’s a very different sense of care than the one I had earlier in my career.

When I was a young physician, I was trained that care was all the nice things that you did that were beyond the minimum. Now, I think of care as the way I bring myself to the room to meet the other person. It is the way I can stay there—or try to stay there—regardless of what is coming up for them and, in the time that we are together, to invite everything into the room. The more that we can both be present with everything, the more there is really potential for a kind of healing.

SS: You’ve discussed how your practice influences your clinical work, but I’m also curious about the other direction. Has your day-to-day work as a palliative care doctor changed your relationship to Buddhist practice?

AB: My experience as a doctor sitting with people who are dealing with serious illnesses has totally changed my worldview. I started out in this work as kind of a materialist: I thought that you have a body and it’s just stuff and you die and it’s over. Sitting with people has given me the sense that something very, very different is going on. Being with somebody at the moment of death and being really present for that, there is clearly something happening that is not described by medical science—there is a profound shift when someone’s spirit leaves the room. That has forced me to recognize that there is something else going on in the universe that I was never trained in. My Buddhist practice is what has allowed me to perceive that.

If I had not learned to stay still long enough to feel inside myself, I don’t think I would have noticed that that was happening. And I see it all the time at work. Everyone [at the hospital] is running around so much, and someone dies and they don’t even notice. They don’t feel it. I think those experiences [of being with people at the moment of death] have tuned me in to a level of my practice that I’m not sure I would have accessed on my own.

Being with people in this way has changed what it means for me to be present in my own body. That has given me a different reference point for myself, but it’s also given me a point of reference about how we are all interconnected. If I pay close enough attention and my mind is quiet, I can actually feel this interconnection all the time, and that is a source of encouragement and a kind of joy and curiosity and awe. Even in really busy moments, I can get a taste of that.