Chapter 6 – Into the World: Dialogue and the Elemental Cycle
Responses to the Elemental Cycle
The responses of the group to the seminar were quite positive. One attendee, who had also been introduced to the elements in Dennis Klocek’s year-long Consciousness Studies course, expressed that the practical exercises made the principles of the elemental cycle much clearer and more understandable than it had been before. Another person applied the elemental cycle in a personal way after attending the seminar, with the following thoughtful response:
I have experimented with applying and integrating your ideas of the alchemical elements into my daily experience. I must say that I have been pleasantly surprised with the effectiveness and clarity that has arisen through the implementation of your ideas, as I understood them. The following is the method I used to apply your findings. First, I began by viewing my experience as a network of relationships. Then I started examining each relationship through the lens of your alchemical model.I found it to be quite helpful in discerning where I was stagnant in various activities. For instance, in my meditation practice I became aware that I was stuck in the Air elemental. I found that I was not engaging in 'listening' during my meditation practice. I had passed through the Earth stage and spent much time in the Water state in which I was processing my meditation. I started then applying the model to other areas of my life and found that I have a general deficiency in the Air element. This allowed me to focus more attention onto the Air qualities and alleviate some blockages and stagnancies in my mode of communicating. While focusing on the Air element, I found myself feeling a two-fold process that seemed to be quintessential in creating experience. I felt that every interaction or relationship comes down to two distinct but dependent forces, namely Push and Pull or Attraction and Repulsion. I brought this up to another participant of the seminar who pointed out to me that the Air element is in fact one of polarities, which fit into my experience during engaging the air element. Basically, I found the model and ideas to be quite helpful and served as a good metaphor to examine how one relates to various experiences in one's life. Another experience I had was the recycling aspect or nature of the process. I found that there is no ending (as is evident in the diagram), but even after 'completing' a cycle of transformation one is left with new facts or information that allows you to restart the process, but with a new vision or perspective. In some ways it seems to be a never ending process of change. It is actually a little daunting if you sit with that feeling, but it is also a freeing feeling that removes the worry of completion or end goal from the equation.
Another person, familiar with the elemental cycle from Dennis Klocek’s Consciousness Studies course, provided a detailed record of what occurred when trying to work with the elemental cycle in a difficult work setting. The response is included here in its entirety because it gives a complete summary of one way that to work with the elemental cycle, as well as to preserve its unique flavor and flow:
Seth Miller asked me to try to apply Earth, Water, Air, and Fire to an area of my life and to write a short summary of what came of that application. This, I thought, would be complicated because I live in a hospital.
Well, I don't actually live there but close enough. I am a physician. Actually I am a brand new physician, also called a resident. I'm pretty certain that they call us residents because we basically live at the hospital. We are not supposed to work more than 80 hours per week because some resident killed a patient after working 30 hours straight a few years back. So someone made a "work hour rule" that limits our in-hospital duties to 80 hours per week. Most of us log many more hours than that in reading and just trying to figure out how to treat our patients. It's stressful and it's hard.
What I am trying to say is that I work long hours so I don't have very much time for “spiritual research”. In fact any “spiritual work” that I do has to also be compatible with my “day-waking” work because that is what I spend most of my day-waking-hours doing.
So when I was asked to do some research I was slightly dubious as I don't have much time to dedicate to that sort of thing. I was worried that I wouldn't have to the time for it. I wasn't always this way. I once in fact took a 7 month sabbatical before getting accepted to medical school to meditate and do artwork and relax (imagine how hard that can be for a type A person!). It was torture (just kidding, it was great) and it was during that time I became familiar with some alchemical principles and the concept of Earth, Water, Air, and Fire.
I knew that even a couple of minutes per day should be enough to do some meditation and to pay attention enough to foster a space internally to get in touch with something beyond just work. So I set out to spend a few minutes a day and failed miserably in paying attention every day because I was so busy. Even so, I have many many examples of how this alchemical method of paying attention to my day helped me overall to maintain perspective and to be (I hope) a better doctor and (I really hope) a better human. I have so many examples in fact that I'll try to stick to one example because it would be too hard to write everything down. The example I'll use occurred during the hardest month of my life and it felt like the universe was hitting me over the head trying to get me to pay attention. (I can be sort of dense when it comes to spiritual matters since starting residency so the universe sometimes has to do that...)
Here then is a retelling of how Earth, Water, Air and Fire helped me to survive the ICU (Intensive Care Unit). Overall, the elemental cycle helped me to organize my information gathering before rounds and to give better presentations to the head physicians. This allowed me to take better care of my patients and to get out of the ICU in less time.
The ICU is what we call the Intensive Care Unit because of the intensity of care that the patients there require. It is where all of the sickest of the sick patients in the hospital go to have very close monitoring and get life-saving interventions. As an intern (first year doctor) in the ICU I had to be the workhorse of the unit. I had to get up a before 4am every morning in order to find out what happened overnight (when it wasn't me staying overnight to babysit the patients as one new doctor had to do nightly) and present all of the new data to the boss-doctors by 7am rounds. During rounds we would discuss the data as a group, presenting what we thought was going on and what treatments were planned for the day to help the patients.
When I first started working in the ICU I was terrified. I was a brand new resident. All of my patients seemed to be hooked up to machines which keep them alive. There were a lot of machines, many of which I had only read about. I had no system for handling data, working through each patient. I had no idea what I was doing.
I knew how to write a SOAP note as I had learned in medical school. For decades doctors have organized their problem solving in the setting of patient care using SOAP notes. SOAP notes are how doctors write down their interviews with patients. It's how we organize our thoughts, S is for subjective data, or what the patient tells the doctor. O is Objective data, vital sign, labs, and the recording of the doctor's exam (with the silly assumption that the doctor's exam is “objective!”). A is for assessment or what the doctor thinks is going on. P is for Plan, what the physician plans to do about the problem. Here's an example of a simplified SOAP note:S: 33 year old female complains of chest pain. 5/10 burning chest pain began this morning after eating breakfast. Nothing helps the pain or makes it worse. It is accompanied by nausea but no vomiting. O: vital signs (blood pressure, pulse, temperature, respiratory rate-numbers go here)
Exam of patient: gen-young woman in some distress; when asked to point to her pain, she points to her right upper abdomen. Lungs clear to auscultation; heart regular rate and rhythm without murmurs. Abdomen obese with normal active bowel sound, tender to palpation in the right upper quadrant; positive Murphy's sign; externals warm with good pulses. Electrocardiogram is normal.
Labs: cardiac enzymes within normal limits (data, data, data, numbers, numbers); Ultrasound of the Abdomen shows gall stones and gall bladder findings consistent with inflammation.
A: 1) Cholecystitis (inflammation of the gall bladder) P: Will observe the patient here and obtain a surgical consult to assess the patient for immediate surgery versus antibiotic treatment and follow up cholecystectomy (removal of the gall bladder).
That’s a basic SOAP note. Basically, this lady came in with “chest pain’ which turned out to be her gall bladder and the doctor realizes this and then decided to call a surgeon instead of calling the heart specialist. The SOAP note helps with this process. That's why it is the universal format that physician's use to communicate with one another.
When I first thought about using the Earth, Water, Air, and Fire cycle in terms of medicine I thought that the work had been done for me. I thought that the SOAP format fit the EWAF format as follows:Subjective Data = Earth
Objective Data = Water
Assessment by Doctor = Air
Plan of Action = Fire
When I thought about that further though, I realized that this was wrong.
Unfortunately I still had to write a SOAP note every morning on every patient in the ICU. I had no idea how to apply EWAF to SOAP. I had to get up to get to the hospital in enough time to gather data to present to my attending physicians by morning rounds. I was so busy the first week I didn't really try to apply EWAF; I just wrote SOAP notes.
ICU SOAP notes are LONG documents. They have a lots of data to present (the “O” section is REALLY HUGE and confusing to a new doctor). As a newbie in this process I could gather data but then I had a ton of information and didn't know what to do with it. I was supposed to be ready and prepared by 7 am to tell the experienced physicians what I thought was happening, what was wrong with the patient, and what we should do about it.
This was awful. They tore us apart. They were mostly civil about it but there's no way to nicely say you're wrong – about everything – most of the time. It was really difficult as a new intern to come in and write notes and gather data and then feel stuck (and stupid and unprepared) as to how to turn it into a bigger picture. The attending physicians (attending equals head physician – the ‘boss’) could just walk up to the patient glance around their room and glance at the flow sheet (full of data) and they could announce what was wrong with the patient, why it was one thing and not something else and what the plan would be for the day's work with that patient. In about 2 minutes. It made the interns feel terrible.
Luck (luck?) would have it for me that I have been blessed with a pretty strong sense of intuition. If I were to pick an element that I most often use and am "in" it would be Fire. So I have always been one of those people who clinically “just knows” what is going on with someone. I quickly gestalt the bigger picture. It is a skill that I can't explain with my data and my lab values. I often have a difficult time explaining it to attending physicians. Especially on a really hard case where nobody can figure out what is going on, I would sometimes say what I thought was happening and why the patient was sick. Then the attendings would look at me intensely with that expression of “what the hell does this kid know?” and then they ask me how I knew. I would often just stand there during ICU rounds speechless (after pronouncing what was wrong with the patient) when they asked me HOW I knew what I knew. I mean I didn't even know what half the machines in there did on my first day but I'd just know it was the guy's pancreas and not his liver that was making him so sick. I just couldn't explain why. This made for some awkward moments there during rounds. Then we'd get some lab value back later that day and then things would get really uncomfortable with questions from the attendings when they realized that I had been right.
The attendings had good intentions, they were just trying to help me to clarify my thoughts and to strengthen my thinking process. A good doctor practices a mix of art and science. I felt rather uncomfortable and scrutinized during the whole process even though they were helping me to develop into a stronger clinician. It was also a matter of there being so much information, it felt overwhelming and I often didn't know where to begin.
I also found that our attending physicians change very often and it was hard to know what each new head doctor (attending du jour) expected from me. I had to be able to figure out how to quickly go through Earth, Water, Air and Fire on each of my patients AND realize who my audience was and how to present to them in a way during rounds that was harmonious and appropriate.
My presentations during rounds to each new head physician became easier once I realized that I could use the elements to communicate more effectively with them. I had always realized that there are different kinds of people (so different kinds of doctors) out there. Some are more Earthy, or Watery, or Airy, and some are much more Fiery. What I mean by this (in regards to the head doctors to whom I was presenting to) is that is that some people like the data and the research and they quote studies to support their treatment plan (Earth). Others see the change in labs over time and see the trends and they base their decisions about how to treat on how things are trending (Water). Still others like to come up with long lists of different diagnoses of things that could be wrong and then rule them out (Air). And some are like me and they just know (Fire) and often have to work backwards to fill in the other parts.
So after a few frustrating days during rounds I had to figure out how my SOAP notes connected to Earth, Water, Air and Fire, and then I could present accordingly to the head physician of the day. I had done enough work with the elements before becoming a doctor to have a fairly good sense of different people and what element that they tended to be in. What I had to figure out was how the ICU SOAP note fit into elemental cycle.
I felt stuck in my work during the first week in regards to alchemical elements and how I could relate them to my daily grind of SOAP notes and work. So when I went to sleep at night for a couple of nights, I asked the question of “how do I relate Earth, Water, Air and Fire to the SOAP note?” Nothing. Then I tried asking, “which element should I focus on to make this process easier?” Then God or the Universe or whatever/whomever you want to call it started leaving little signs around – the hitting me over the head kind of signs that I seem to need when I'm busy so that I pay attention to what the Universe is trying to help me with.
By the end of the week I had nurses coming up to me and telling me about surfing, about their sons surfing, and about fishing. Random pictures would be left up on the work computer stations from people's internet searches, and I'd sit down to work and there would be pictures of huge waves, of surfboards, of water. Everywhere, water. Now the scientist in me chalked all of this up to coincidence. There are a lot of people who like water activities who happen to work in the ICU. They put things on the computer. (The logical part of my brain is always looking to explain away anything that could be construed as a message from the spiritual world.)
Then one day after one of my patients literally had water pouring out of his abdomen after a surgery (he had a liver disorder...the liver is the organ most associated with Water in traditional alchemy), another came in with too much water in his lungs from a liver problem (he was literally drowning) and three different conversations were happening around me having to do with surfing, fishing, or a trip to the beach, I finally (I did say that I could be dense) went “Oh water!”
So what about water? I then realized then that I didn't even know which part of the SOAP note was the water. There was no section of my notes which gave attention to the Water question "what is changing?" I went around before I left for home that day and tried to compare trends on my patients to what had happened over the week. Suddenly patterns emerged that I hadn't seen before and I had a whole new aspect of ICU patient care which literally jumped out at me. By just being relaxed and wading through the changing data I could see how our treatments were working over more than just the snapshot that I had been paying attention to. The next morning I added a new section to my data section which took a little extra time but made the assessment and plan section faster. I just jotted down the directions of change on the important labs. That's all, it seems really simple. It's really obvious if you are watching one or two pieces of data. With the huge number of things that we have to keep track of in the ICU though, I just had too many changing variables to keep track of without writing them down. Suddenly I had a way of organizing SOAP notes that honored each part of Earth, Water, Air and Fire and this was helping me to understand the patient better. I was also able to present more effectively to the attendings because I had a more well-rounded view of the patients.
Here is my system for using EWAF for organizing my SOAP notes:Earth is the facts and data. In the Soap note, this is the S and the O (the subjective and the objective data).
Water for me is running the data through change over time. So not just asking what is Mr. Smith's sodium level today, but also paying attention to how was it yesterday and where I think it will be tomorrow. The direction of change in the data helps immensely in processing large amounts of data as we do in the ICU. This is the unnamed part of the SOAP note that I added to the data (S and O) sections of the note to remind me of the trends.
Air for me is the assessment part of the SOAP note which is not usually an answer in the ICU but more of a perpetually changing question. For instance, I have someone whose sodium is getting lower and I come up with all of the things that it COULD be (this is called a differential diagnosis in medical lingo). Air in medicine for me are the questions “is it this, OK is it that, is it this, what about this, how about that?” You just keep going until every possibility that you can think of is exhausted. Fire is the gestalt of the patient, the “big picture” which is where the P (plan) of SOAP notes comes from – i.e. an answer to the question “what we should do about it?”
This also helped me in my presentations to attending physicians because I could talk more in whatever section/element which that attending wanted to hear. This made rounds less anxiety-provoking and more fun. Plus when I got a gut instinct about what was going on with a patient, I knew to do the extra step of researching the Water level (how the data changed) to have a ready answer when the attending asked me “how do you know that?”.
So this is how I applied Earth, Water, Air and Fire to the Intensive Care Unit while I was a new doctor working 80 plus hours per week. If alchemy could help someone in that situation, then I certainly think that it has utility in many more aspects of life.
This kind of feedback was very encouraging, and expanded my interest in coming up with a better way of communicating the essential aspects of the elemental cycle in an efficient but detailed way. I wanted to provide just enough of a basis upon which individuals could apply the cycle fruitfully without need of additional help. To this end I wrote a primer (a revised edition of which is included here as Chapter 8), along with a series of feedback questions, and distributed it to everyone I could think of who might possibly respond.
I only received a handful of responses, but some of the most pertinent results are included below:
To the item “On a scale of 1 to 10, rate how likely you would be to try using the elemental cycle again in your own life, where 10 is ‘would definitely use it again’ and 1 is ‘would definitely not use it again’”, the lowest response was an 8, with one response indicating a 2-9 scale, depending upon the topic.
To the item “On a scale of 1 to 10, rate how easy it was to actually apply the elemental cycle to your chosen phenomenon, where 10 is ‘extremely easy’ and 1 is ‘very difficulty’”, the lowest response again was an 8, while one responder usefully pointed out that “I find it is less a matter of the mandala and more of my time/patience on my part”.
To the item “On a scale of 1 to 10, rate how useful the elemental cycle was in helping you understand and work with your chosen phenomenon, where 10 is ‘extremely useful’ and 1 is ‘not useful at all’”, the lowest response was a 9.
Every respondent reported that they felt they were able to fully complete at least one cycle from Earth to Fire.
Participants were asked to describe, to the extent that they were willing, of any Fire experiences or insights. One response: “An amorphous question that I have held for a long time gained shape, became objective, and seemed to speak to me, from outside of me, seemingly larger than myself.” Another response:
I have had a few fire experiences. I think the most clear was in mediating. I simply was working on a meditation exercise. After a few months of working on it, and going through some hard parts where I felt like giving up - one day I just understood - I had been doing the mandala. It was a deep knowing about something which had eluded my consciousness for months. The total lack of expectation of any answer on my part I feel was what lead to the clarity of the insight.
and another response:
My question was “How can I grow spiritually?” It did feel like an “aha” insight as I responded to the Fire questions. There was a great complementarity to working with the elemental cycle while reading a book by Eckhart Tolle on spirituality. It was interesting to note a feeling of release of tension, a sense of peace, once completing the fire part of the cycle.
The insight that I came to that was most powerful to me is that right now my spiritual growth is not so much about searching (my assumption going into this – need to read and study more, think more etc.) as it is about learning to be, to be in the moment and alert. I recognize that I’ve been in a frame of mind that “it” (the truth) is out there and I just need to find it. Now I believe my spiritual growth is about being open and letting go of fear about what I might learn along the way or what anyone else will think of what I learn. Open, attentive, awake…this is my spiritual “work.”
Responses to the question “Is there anything you can note about the process of working with the elemental cycle that seems important to indicate?” included “The journal – the activity of noting my impressions and thoughts in the journal helped me to focus and move along” and
Due to family circumstances, my responding to the questions was erratic timewise from the suggested way of doing it. This didn’t seem to make a difference. I think that may be because I had read through all the questions prior to starting my journal and so I had an overall concept of the process. What I found was that I carried the sense of the questions in my head and would be thinking about them off and on even when I wasn’t sitting down to write anything. So in some sense, work with the cycle was going on almost continuously over a period of several weeks.
as well as a useful series of questions:
I'm wondering how far can [the elemental cycle] be abstracted away from the "strange" language of alchemy, and into easy to approach terms and concepts? Is less more? Or does there need to be a certain level of complexity? Could you get away with explaining it less? How much does the reader need to know of the background, or can they simply apply the questions and go with it?
All of the responses I received, including less formal ones from a variety of people aware of my attempts to work with the elemental cycle, have been generally encouraging and positive. The theoretical and experimental basis for the practical value of the elemental cycle seems beyond doubt. As noted above, however, much depends upon the investment of the individual, as it provides the ‘fuel’ upon which the elemental cycle operates. More on this in Appendix A: The Fifth Element; now we turn back specifically to how the elements provide a practical way of approaching communication.
