Gurdjieff’s Aphorisms Illustrated in the Practice of Medicine

Richard Sandor, MD

t has been more than fifty years since I first became acquainted with Gurdjieff and his teaching. The teaching itself is both comprehensive and complex, but some of its essential aspects are reflected in his aphorisms.[1] In what follows, I have taken a few of these sayings that seem to me to have “come to life,” so to speak, in my career as a physician. There have been many more lessons than these along the way, for as Gurdjieff promised, life itself has become the teacher.

Gurdjieff’s aphorisms reflect, I think, one of the most appealing things about his teaching—that it is practical. Among the various phrases used to define “aphorism,” the one I like best is this: “often leaving a lasting impact on the reader.” These little bits of wisdom are meant to be put into practice. They don’t require going to a special place, reciting scripted words, or engaging in rituals of any kind. His aphorisms are a sort of shorthand for his “Fourth Way”—a Way toward awakening, not in the seclusion of a monastery or ashram, but in the midst of everyday life. That means at the breakfast table, in biochemistry class, on rounds in the hospital, or even in taking out the trash. And for that, something memorable and concise is indispensable. “Remember yourself always and everywhere” is, for me, the most important of Gurdjieff’s aphorisms—nearly impossible, but practical.

When I first began thinking about this essay, I was a little puzzled by the fact that most of the life lessons I have received as a doctor came early in my career—either in medical school, as an emergency room doctor, or as a novice specialist in the treatment of drug addicts and alcoholics. But on reflection, I see that this is the nature of education—the lessons come early, then comes working to put them into practice.

“The chief means of happiness in this life is the ability to consider externally always, internally never.”

At the huge county hospital where I did my early medical training, the status of medical students was somewhat ill-defined and subject to change. We were there primarily to learn, of course, but the crush of clinical duties that fell upon the interns and residents could not be ignored, and they often pressed us into doing more than we were supposed to.

Intern: “Here. Hold this. When I say, push it in here.”

Medical Student: “But … I’ve never done this …”

Intern: “Just do it—don’t worry. If you’re having trouble, just sing out and I’ll help you.”

Back then, intensive training for medical students on the medical and surgical wards began in the third year. My first rotation of this kind was chest (respiratory) medicine, and I was assigned to a team of two interns and a resident. They, in turn, were supposed to assign me to a patient I was to “work up” and follow throughout the hospital stay.

My rotation landed in the middle of a flu epidemic. It wouldn’t be officially recognized as an epidemic for another month, but early on, it was clear that a bad virus was having a field day in the city. Patients by the ambulance-load were pouring in from the emergency rooms of private hospitals which would not admit indigent patients. I finished my classes for the day and reported to the resident in charge of my assigned ward. The man hardly had time to introduce himself. Patients were coming up from the ER at such a rate that there was no space for them in the ward rooms, and the corridors were filled up with beds.

Archie, the resident in charge of the ward, thrust a fresh chart into my hands, pointed me to one of the beds in the hallway and said, “That one.” And from 7:00 to 9:00 that evening I did my medical student’s work up—a notoriously detailed examination of the patient’s history and physical condition. I scribbled my five-page admission “note” in the chart and announced to the resident that I’d be leaving for home now. He checked my work, looked me up and down, and said,

“Listen, we could really use a hand. Would you help out? Joe is already behind on two admissions and Tom has a really bad lunger that he’s going to have to transfer to the ICU.”

I replied, “Just a regular admission note and orders?”

“Yeah, yeah. Not the whole med student thing. Just the basics. We’ve got to get these people taken care of. Bring me your write up when you’re done. I’ll co-sign it and help you with the orders. Thanks.”

He thrust another chart into my hands and pointed to another patient in the hallway. I called my wife and told her I didn’t know when I’d be home.

Initially I was flattered and excited to have been found worthy to contribute to such important doings, but by about midnight the excitement was wearing thin, and I was losing patience with the whole business. A litany began in my head: “I’m only a medical student! I’m not supposed to be here all night! The interns and residents are getting paid to do this, not me. I’ve got a whole day of classes tomorrow, and I’ve got to present this case to the attending physician tomorrow. Why are they using medical students for this? Why doesn’t the County spend the money for more staff?” Classic “internal considering” à la Gurdjieff.

I didn’t say anything out loud, but it must have been written all over me, because the resident came over and looked me in the face.

“Hey, you can go home if you want. You don’t have to stay, but the work you’re doing is a big help.” He paused, looked down for a moment, and then continued, “And I’ll tell you something else. This is it.”

“What?”

“This is it.” He laughed and went on, “I mean this is Medicine—this is your life. Welcome.”

“What do you mean?” I was amused by his apparent delight but not yet getting his point.

“I mean this is what it means to be a doctor—odd hours, inconvenient interruptions, doing things now you’d rather put off or ignore. This is it. It starts now. You can accept it, or you can fight it for the rest of your life.”

In a flash, I understood. This was the beginning of my life in Medicine. No more fantasies, no more daydreams. This was the reality. This is what I had signed up for. Of course, I hadn’t known that this was what it would be like. Nevertheless, here I was, and the reality couldn’t be denied.

Archie was saying one more thing, too—one very deep thing, albeit in a very light way. In a few words, he was telling me to wake up, to stop being so self-concerned—that I wasn’t really in charge of what happens in life, much less a life in Medicine. He was saying, “Why not start out right? Being a doctor begins with accepting the unexpected. Why begin by fighting it? You can’t win, and you’ll just make yourself miserable if you try.” It all coincided exactly with what I was hearing at the Gurdjieff meetings and reading in the writings of Gurdjieff’s students. This was my opportunity to put it into practice.

As I said, this whole realization flashed through my mind in a matter of seconds. I stopped complaining and got down to the work at hand. As the internal considering dissipated, external considering—being concerned with others—naturally took its place. Miraculously, in another thirty minutes, the whole ward quieted down. Admissions stopped. Patients were receiving the care they needed. The interns and nurses caught up with their work, and Archie told me that I could go home. The crisis had passed, they were in “fine shape,” and there wasn’t any further reason for me to stay. He clapped me on the back and sent me on my way.

Like all great lessons, this one has had a life far beyond the circumstances that gave birth to it. It was about more than letting go of self-concern—“internal considering” as Gurdjieff describes it—it was also about the fact that small differences at the beginning of any endeavor have dramatic consequences later on. It’s like aiming a bow and arrow—an inch or two to the left or right of the target as the arrow flies away will mean a total miss at fifty yards. We rarely see those moments when a small shift in attitude can make everything turn out differently decades later. And even after all this time, internal considering periodically pops up on its own, but more and more often, the aphorism also appears and helps me let go.

“Only he can be just who is able to put himself in the position of others.”

For a man just admitted to the hospital, the intoxicated patient with singed eyebrows and a hacking cough looked remarkably happy—certainly, a good deal happier than I was. I only hoped that he was the last admission I would have to “work-up” that night. I glanced at the accompanying emergency room chart, which gave his name as “John Doe #14,” and turned to my charge.

“What’s your name?” I asked.

“John Doe,” he replied cheerily between coughs.

“No. No.” I sighed my indulgence and asked again. “That’s the name the hospital gave you. We don’t know your name—what’s your real name?”

“Hack, hack. John Doe!” He insisted.

“You mean, your own name, the name you’re known by is ‘John Doe?’”

“Ya. ‘John Doe.’ Truly, doctor, this my name. John Doe.” More cheeriness.

OK, I thought, the hell with his true identity. He was, I hoped, the last of the dozen or so patients I had worked up over the past 12 hours, and I was simply too tired to pursue the question of his real name. Besides, what did it matter? Finding out who he was wasn’t going to influence the diagnosis or treatment. Truly, I thought he was right. Let him be “John Doe” for the night. Even “John Doe #14,” if he liked. Oddly, and whether from exhaustion or charity, I wasn’t angry with the man. On the contrary, he made me smile.

As most everyone now knows the labels “Jane” and “John Doe” are given to ER patients who cannot otherwise be identified—either by papers, friends, relatives, or the police. Most often at County Hospital, they were overdose cases—people who had attempted suicide, or drug addicts who had miscalculated the strength of a fix. Both were the kind of patients who irritate doctors and nurses, overtly or otherwise. From our point of view these people had more or less intentionally harmed themselves and, as a result, were forcing us to take time and energy away from patients who hadn’t done anything to “deserve” their ills. Of course, these pseudo moralistic judgements were informed only by ignorance. We hardly ever learned what in these people’s lives had brought them to the desperation or confusion that had landed them at our doorstep. Abuse, neglect, mental illness? We didn’t know.

In any case, Mr. Doe #14’s blithe happiness made it easy for me to treat him decently—the man positively glowed with contagious delight. But he also had me puzzled. I had never encountered a conscious patient, apparently capable of telling me who he was and yet also unwilling to do so. And gleeful about it to boot. But, as I say, he was at least a happy drunk, amusing himself and anyone who would listen to his proclamation that he was, indeed, “John Doe.”

Mr. #14 made me happy for another reason too. He’d been brought to the hospital with a nasty case of smoke inhalation, and each time he spoke, the charred wood smell of his breath reminded me of a great forest fire my physician-father, brothers and I had driven through on a camping trip through Alaska some fifteen years earlier. It recalled to my mind a simpler, happier time—and the memories brought a welcome relief from the dispiriting confines of County Hospital. It seemed that the instigator of my wood-smoke reverie had been drinking and fell asleep on his couch, lit cigarette in hand. The couch ignited; neighbors summoned the fire department, and, in the end, Mr. Doe #14 had come under the care of the second Doctor Sandor.

It wasn’t until 11:00 am on the following day that I was able to return to Mr. Doe. I was pleasantly surprised to see him sitting up in bed, reading a newspaper and drinking a cup of coffee. He no longer needed supplemental oxygen and, except for a deep and productive cough, was doing very well. He recognized me as his doctor and carefully folded his paper.

“Good morning, Doctor Sandor.”

“Good morning. So, you remember my name? What’s yours? Last night you wouldn’t tell me.”

“Oh yes, I tell you several times. ‘John Doe.’”

“John Doe?!”

“Ya, Doctor, we go through all this last night before. You are not believing me then, either. Truly, my name John Doe.”

Slowly, the man’s accent and odd syntax penetrated my sleep-deprived consciousness, and I began to take him as a person and not just a numbered case.

“Where are you from?” I asked.

“I Russian.”

Growing suspicious, I asked another question. “What was your name in Russia?”

“Ivan Dolbyn.”

“So, how do you spell your last name?”

“D-O-L. ‘Dol.’ Like I tell you last night, Doctor, John Dol. They make it short when I come to US. I don’t know why.”

Over the next few days, Mr. Dol (ex Dolbyn, ex Doe) explained that each year, on the anniversary of his liberation from a German P.O.W. camp, he got roaring drunk. The rest of the year, out of respect for his incipient alcoholism, he abstained. His story, as I learned in bits and pieces, still brings me to a strange mixture of sadness and hope. While he’d been imprisoned by the Nazis (who had made good use of his skills as a machinist), Stalin had been busy exterminating his family. Since there was no home or family to return to when the war ended, he had emigrated first to France, and then to the United States.

His Old-World manners and self-possessed dignity were a gentle reminder of much more than vacations past—of civility, kindness, patience, and, for me, gratitude—gratitude for being alive, for having honorable work to do, and for a father who had made both possible.

I’ve looked after a good many more Jane and John Doe’s since internship. I’d like to say that I’ve treated them all as respectfully as Mr. Dol treated me. But I haven’t always succeeded. Even now, some fifty years later, I forget Gurdjieff’s maxim of putting oneself in another’s place and become frustrated with people who don’t act the way I want them to. But then, too, more and more often these days, in the midst of some self-centered inner tirade or other, I remember Gurdjieff’s aphorism about what makes it possible to be just to another human being, and I am saved.

“Love work for work’s sake and not for its gain.”
(Gurdjieff attributed this to his father.)[2]

After completing my internship at LA County Hospital—still not certain what to do next, I signed up for a year of a pathology residency, hoping to continue some research I had been working on since college. I soon discovered that I was not cut out for academia, and I was barely earning enough to support my growing family. So, I took a job moonlighting as an emergency room physician in South Central LA. After a few months working there once a week, I quit the pathology residency and began working full time in the E.R.

At that time there was a saying about emergency room medicine—that it was “95% boredom and 5% terror.” The percentages might have been off a little, but overall, the saying conveyed the reality of the place. Many local folk used the ER as a walk-in clinic for minor problems that were definitely not emergencies, but at least once or twice a day, the paramedics would come screaming in with someone who was seriously ill or injured.

The boredom part was what really got to me. During these long periods of waiting for something serious to happen, I had only a couple of choices—stay in the little staff room trying to read a newspaper or magazine while the nurses carried on about husbands, romances, doctors, and hospital administration; or, hang out in the doctor’s lounge and listen to my colleagues carry on in the same way—only about their investments, spouses, families, the government, etc. Neither option was very appealing.

Then one day, a woman came in nearly ready to give birth to her fourth child. Before I even had time to glove up, her general practitioner arrived in the emergency room to do the honors. He was an older man and had that sort of practical wisdom that country doctors used to exude. I liked to follow along with him when he took care of his patients. He asked this woman to do what he had trained her to do—to go into self-hypnosis for the delivery of her baby. Very slowly, she raised her right hand, touched the back of her hand to her forehead, and promptly fell into a trance. He then went to the foot of the bed to catch number four. A simple, easy delivery. I was impressed and began studying hypnosis. I knew that Gurdjieff had been a “professional hypnotist” in his early years and that he described the “normal” condition of humanity as a kind of “waking sleep.” So that added to my interest.

At about the same time, I joined my father in his new hobby of collecting rare medical books, and I acquired several of the classic books on hypnosis. One was a seminal work by the French physician Hippolyte Bernheim, Jean-Martin Charcot’s great rival in the 1890s. I believed I had the English translation of this book already titled Suggestive Therapeutics[3] translated by Christian Herter, M.D., and a brilliant idea popped into my head—I would translate my copy and check it against Herter’s. “Down time” put to good use; boredom problem solved; college French kept alive; and I would be learning about the origins of hypnosis.

After the first nine pages, I checked my translation, and discovered, to my astonishment, that they were totally different. I knew my French wasn’t that bad, but the full significance of the differences didn’t become clear to me until much later. I was enjoying myself, and the boredom problem had been neatly solved. So, I just kept working at it. Before long, it was clear that something was seriously amiss—even the chapter titles of my book didn’t correspond to Herter’s. After about 100 pages, I finally did what I should have done in the first place and translated Bernheim’s introduction. In it, he noted that this was the second volume of his two-volume set. Herter had translated volume one. I had volume two. A search through the Oxford Catalog of Books revealed that this second book had indeed been translated already—into German by a certain Sigmund Freud, and also into Dutch by A.W. van Renterghem—but never into English.

In time it became clear to me that I did not love being an ER doc. The income was good; the hours were manageable; and I felt I was being of service to my fellow human beings. But I didn’t love it. I was still uncertain about where I was going, but learning about hypnosis had awakened an old interest in the “mind-body” connection. And at a particular moment—I remember it clearly—I gave up trying to plan out my career. I would just take the next step and see what it led to. That meant applying for residency training in psychiatry and leaving the ER. The admissions committee at UCLA’s Neuropsychiatric Institute were impressed with the translation project and offered me a position as a first-year resident in psychiatry. So, even though I hadn’t taken on the translation project for any particular “gain,” a great benefit came nonetheless, and I learned an important lesson about the value of doing things for their own sake—results do come from doing something you love, but that isn’t why you do it.

“By teaching others you will learn yourself.”

After finishing the psychiatry residency, I returned to the emergency room and continued to work there three days a week. That paid the household bills while I set up a little office a few miles from my home. I equipped it with some nice furniture and biofeedback equipment and waited for the patients to arrive. A few did arrive from my UCLA contacts, but overall, the practice was a complete failure. Then came word that the hospital was going to hire a new group of doctors to take over the emergency room. Just as the prospect of having no income was sinking in, the medical director of the alcoholism rehabilitation program upstairs in the hospital asked me if I would like to take over. He was moving to Washington. Up to then, all my clinical experience with alcoholics and drug addicts had been, at best, unpleasant. Nevertheless, thinking that it would only be a temporary position, and with considerable reluctance, I accepted.

As part of my duties at this program, I was to give a weekly lecture to the patients. The program director gave me an outline to follow, but it was the standard “the-bad-things-that-will happen-to-your-health-if-you-keep-on-drinking” pap that turns the doctor into a poorly disguised preacher. It bored me and I had little confidence that it would do the patients much good. Instead, I held question and answer sessions about how the body worked, the biology and chemistry that resulted in addiction; and, in return, my patients began to teach me about the experience of being addicted. A few weeks after I was hired, the program hired a new program director—a bearded, burly, gruff Bostonian, an ex-con (he’d listed his educational qualifications for the job as “Jackson State,” the Michigan penitentiary), and now, recovering alcoholic. This man, Tom Redgate, sized me up, ventured that even though I was a doctor, I “might be educable,” took me under his wing, and introduced me to Alcoholics Anonymous.

At these meetings I heard the stories of people who’d gotten sober without any professional help whatever, and the dim light of comprehension began to dawn in my mind. Listening to people speak about their experience of recovering from addiction (about which I’d learned nothing in my excellent academic education), I began to understand that addiction was an extreme example of the “automaticity” that Gurdjieff described as ruling our lives. I incorporated this idea of addiction-as-automaticity into my lectures, and it clearly helped patients understand what had happened to them—and why abstinence was necessary for recovery. I began to love my work with alcoholics and closed my office practice. My vocation had finally found me. And, thus, having started out as a “teacher,” I myself learned.

“Remember you come here having already understood the necessity of struggling with yourself—only with yourself. Therefore thank everyone who gives you the opportunity.”

The hospital secretary buzzed me on the intercom. “Doctor Sandor, you have a phone call from Jeff _______.”

I recognized the caller as a former patient who had been a pleasure to work with—especially so because I had been able to convince him to try a medication for panic disorder. For some time, he had been self-medicating his panic attacks with alcohol, and in the end, had become addicted. He had had some periods of sobriety, but at some point, would have another full-on panic attack, drink to suppress the symptoms, and then be unable to stop. He had rejected the idea of medication in the past—based on the idea that taking any “mood altering” drug was a violation of sobriety. After much discussion, he had finally agreed to a trial of the medication and had done remarkably well. So, I expected this to be a pleasant phone call. After a brief greeting, he told me the reason for his call.

“You violated my confidentiality, Doc. You told Michael that I was taking Zoloft. I didn’t give you permission to do that.”

I was stopped in my tracks and paused for a long moment. “I shouldn’t have done that. I’m so sorry.”

“It’s OK,” he added. “I’m not going to sue you or anything, but I don’t want you to do it again with someone else, so I thought I’d better let you know about it.”

In addition to being extraordinarily generous, he was absolutely right. Jeff had actually referred Michael to my program for treatment. And in my zeal to encourage Michael—also reluctant to try a medication for his anxiety disorder—I had told him that Jeff was taking the same medication and was really doing well. I had acted thoughtlessly.

Almost from day one in my medical training, I had been taught never to admit having made a mistake—especially to a patient or their family. This was a cardinal sin as far as malpractice defense attorneys were concerned. But Gurdjieff’s aphorism and Jeff’s magnanimity made it possible for me to struggle with myself and admit my error. Thanks to both, I have never forgotten this important lesson.

At this same program, I had another experience of the value of this aphorism. It came at the end of one of the weekly lectures I gave patients. This was a tough group. The program was contracted with LA County Health Services to provide rehabilitation services for indigent alcoholics, and many of my patients had spent time living on the streets and/or incarcerated. For the most part, they did not hold back in deference to a young doctor. Nevertheless, I always left time for a question-and-answer period after my presentation. And on one occasion, a patient in the front row raised his hand,

“Say, Doc, I have a question for you.”

“Sure, fire away.”

“What’s that in your shirt pocket?”

I looked down with some chagrin at my pack of Camel cigarettes.

The patient stood up, and as he walked out announced, “You have nothing to tell me about addiction, pal.”

I can’t say I was thankful at the time for this patient having made me feel ashamed of myself, but at some level, I knew he was right. I could not in good conscience present myself as a specialist in Addiction Medicine and continue to smoke cigarettes. A few months later a nasty chest infection forced me to stop smoking for a week. By then I had learned from my patients that recovery from addiction was all about not starting again, and I never have. That was more than forty years ago, and I now extend my heartfelt, if belated, thanks to the man who brought me up short about my own addiction. As a result, at age 78, I am still able to hike into the Sierras at 10,000 feet without any shortness of breath.

How is it that aphorisms come to life in this way? The ancient saying, “As above, so below,” quoted by Gurdjieff, is helpful here. Turn it around (“As below …”) and think of an aphorism as a seed—a condensed packet of wisdom, dormant and waiting to take root and grow. But a vegetable garden—where plants are grown to nourish a human being—doesn’t just happen on its own. The harvest requires work. You have to prepare the soil, plant the seeds at the right depth, fertilize and water them, do what you can to keep the weeds and pests at bay, and so on. And in their own time, the seedlings appear. It is all lawful—if the conditions are right, the seed has to grow. Henry Drummond, in his wonderful book, Natural Law in the Spiritual World,[4] echoes the same idea from a scientific and religious perspective—the laws governing the natural world hold true for the world of the spirit. By analogy then, you do your morning sitting practice every day, attend group meetings and movements classes even when don’t want to, help maintain the Foundation property on weekends when you’d rather go fishing, contribute money regularly, read the literature and study the ideas instead of watching TV … and the lessons come. When, where, and exactly how may be a surprise, but the law is the law. And it turns out that you are not alone. Gurdjieff invites you to follow him, and, if you have tended your spiritual garden as he recommends, the aphorisms do indeed come to life. □

Dr. Sandor is a psychiatrist specializing in the treatment of substance use disorders and is a former President of the California Society of Addiction Medicine. In addition to professional publications, Dr. Sandor has published several essays in the periodical, Parabola, a translation of Bernheim’s New Studies in Hypnotism,[5] and Thinking Simply About Addiction.[6] Dr. Sandor has been a member of the Gurdjieff Foundation of Los Angeles since 1969 and currently serves as its President.