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Ann Thorac Surg 2007;83:1927-1933
© 2007 The Society of Thoracic Surgeons
Cardiothoracic Surgery, Oregon Health and Science University, and Pediatric Cardiac Surgery, Doernbecher Children’s Hospital, Portland, Oregon
* Address correspondence to Dr Ungerleider, Cardiothoracic Surgery, Oregon Health and Science University, John C. Hursh Chair, Pediatric Cardiac Surgery, Doernbecher Children’s Hospital, 3610 SW Veterans Hospital Rd (8451), Portland, OR 97239 (Email: ungerlei{at}ohsu.edu).
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Introduction |
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It is about a journey that I am on. Although deeply personal, I have decided to share it with you in the hopes that some of you will also find important meaning in it. I believe it is about a journey we are all on [1–3].
The story is about a young man named Parsifal, who is innocent, passionate, idealistic, and ambitious. He sets forth to accomplish great things that will make a difference in the world. And of course, bring him recognition. Along the way, Parsifal has epic adventures, and eventually, he finds that the journey hasn’t really been about him after all—it is about something much larger than he.
The story of Parsifal is an old story that dates back to around 1130 AD. Many writers have referred to it as the "hero’s journey" [2, 4, 5], and it traces our path through the chapters of our career. The journey requires a period of Soul Searching (which is really about reconnecting to the call), and it finally leads to Enlightenment and Transformation.
This journey is universal to each of us, and to our profession. We are in the time of reconnecting to the call. It is a time when we redefine our pursuit. It is a time of magnificent opportunity [6].
Man’s quest for the Grail* is about the journey of every person who searches to find what he or she is truly meant to be, and how their life has meaning. That is why we search for it so passionately.
In the story, you may recognize yourself, or at least some pieces of yourself, in Parsifal. So, please, open your hearts and your imagination and most of all, remember that most wonderful of stories: the story that is you...
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Prologue |
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How did this happen to such a great and mighty king? Legend has it that when he was a young and virile knight, he was full of vision and he sallied forth to find conquests to consummate and validate his vision. He was a powerful knight, and his conquests were legendary. In a world that worshiped knights, he was a leader, and he thought he would never fall.
One day, he came across a pagan knight—the knight of sensuousness and earthly pleasures—the knight of earthly passion. This powerful knight enticed our hero into battle. They did what knights do: they lowered their visors, leveled their lances, and rode with great fury towards each other. The knight of vision and the knight of passion clashed in horrifying combat. The pagan knight was killed, and the Vision King received a terrible wound to his groin. The groin wound means that the Vision King, king of the Grail Kingdom, our kingdom, is wounded in his generative ability, which diminishes his capacity to create and to innovate. The Vision King is too ill to live as he is, but he is unable to die.
The implications of this battle are enormous. In the Grail Kingdom, passion is dead and vision is left badly wounded. How can this have happened to our kingdom of thoracic surgery?
The Grail Castle is in serious trouble.
The Vision King presides over his court in the Grail Castle where the Grail,* the chalice from the Last Supper, is kept and worshipped in a nightly ritual [4, 7, 8]. The King lies on his litter enduring his suffering while a procession of profound beauty takes place. A fair maiden brings the Grail, which in keeping with the transformative vision it can bestow, glows with light from within. Each person receives wine from the Grail and realizes their deepest wish even before they voice it. All, that is, except the wounded King, who may not drink from the grail. Only those in whom creative forces still stir can quaff its nectar of vision-granted. This surely is the worst deprivation of all: to be barred from the healing essence of creativity and salvation when it feels like you are surrounded by others who seem to be getting what you want. And it is frustrating because you have no idea how to get that satisfaction for yourself.
But that is exactly what happens when vision is wounded and passion is dead.
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Innocence |
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I would like you each to take a moment to appreciate that Parsifal quality that exists in you: your own unique spark that believes you can leave behind something meaningful and important. It was probably there when you decided to become a thoracic surgeon, or to pursue any dream, and it is still there! It is important that you connect to this piece, because it will be our salvation, and I am glad you have it with you today.
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Hearing the Call |
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Training |
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"You want to be a knight?" Why you are nothing more than a foolish boy. A knight of King Arthur’s court needs to be serious. Full of himself. Well ... Godly."
But Parsifal has a certain sweetness, and he convinces the knights to bring him to King Arthur so that he might be duly knighted, and they share a twinkling smile. He goes to King Arthur’s court and learns that the usual process for becoming a knight takes many years, some of which can be spent in a lab, and if he is willing to accept this requirement, it will help him in his quest.
During his training, Parsifal encounters Gournamond [7, 8], who becomes his Godfather. Today, we might call him a mentor. Gournamond truly cares about Parsifal and wants to guide him as he learns the responsibilities of being a knight. Perhaps you have had Gournamonds. This is a nice moment to be silently grateful for them. I have had several.
Dr David Sabiston created an environment that fostered learning and growth. He was never easy on me as he pushed me to my potential, and I never doubted, not for one instant, that he cared deeply about me, and in fact, for all of us who were his students. I am grateful to have had the benefit of his incomparable support. Dr Paul Ebert taught us by example, and I have enjoyed embellishing my stories about him because I don’t think it is possible to exaggerate what is in his heart and what he gave to those of us fortunate enough to learn from him during our training. And Jean McLendon. It was from Jean that I learned the importance of asking the Grail Question. It is part of what I hope you learn today.
Gournamond teaches Parsifal information vital to attaining manhood: he must never seduce or be seduced by a fair maiden, a metaphor for fleeting, earthly pleasures (rewards, achievements, stuff). And, he must search for and serve the Grail Castle with all his might. At the end of the training period, each knight has the opportunity to enter the Grail Castle. He must be prepared, for when the Grail is passed to him, he is to ask a certain question, and simply by the asking, he can heal the wounded king. In that moment, when he has the Grail in his hands, he must ask:
"Whom does the Grail serve?"
What would knighthood be worth if it were not for some noble end? And the Grail Castle, as you may recall, is in serious trouble.
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Beginning |
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He is informed that there is no habitation within 30 miles. As he grows weary and approaches desperation, Parsifal encounters a man who seems to be in terrible pain and yet who inexplicably appears to be waiting patiently for him by the side of the road. He asks the man if there is any place to stay the night. The man, who is the Vision King, invites him to his humble abode. "Just go down the road a little way, turn left, cross the drawbridge."
Parsifal obeys and the drawbridge brushes the back hooves of his horse as it snaps shut behind him [7, 8]. It is very dangerous to enter the Grail Castle, and many a youth is unhorsed—they lose touch with the core of who they are and get carried away with their own myth—as they make the transition from what is valued in the external world compared with the inner world of the Grail Castle. In the Grail Castle, we are expected to ask difficult questions and be open to the answers. That takes enormous courage.
A great ceremony is in progress. The Vision King lies groaning in agony on his litter, and a fair maiden brings in the Grail itself. A great banquet is held, and everyone is given what he or she wishes from the Grail even before they formulate their wish. Everyone, that is, except the Vision King. Because of his wound—the groin wound that has impaired his generative capacity—he is deprived of drinking from the Grail [7].
The Vision King’s niece brings a sword that the King straps to Parsifal’s waist. This is the sword of experience, and it is to be Parsifal’s for the rest of his career. Its metal is magical and grows stronger with age—a gift to make him an even mightier knight. From this sword, Parsifal gains power to accomplish the remaining tasks of his life.
Another gift is available at the Grail Castle, but Parsifal does not pass the required test and therefore does not receive this gift. There is a legend in the Grail Castle that one day an innocent fool will wander into the Castle, and when the Grail is passed to him, he will ask the Grail question, and heal the wounded Vision King and with him the entire Grail Kingdom. Everyone in the Castle—except Parsifal—knows this legend and watches keenly to see if Parsifal, who certainly has all the attributes of an innocent fool, will ask the healing question.
But Parsifal does not ask. He is mute in the presence of the Grail and the Vision King. Soon, the King is taken, groaning and writhing in agony, to his chamber. The other knights and ladies disperse, and Parsifal is escorted to his sleeping chamber. The next morning, Parsifal finds himself alone, on top of blankets in the middle of the deep forest. There is no Castle to be seen or any other habitation for 30 miles.
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The Pursuit of Learning, Achievement, and Recognition |
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Some of you are in that learning phase. It is an exhilarating time. Someday you will need all you have learned when the Grail Castle presents itself again. As it will.
It takes 20 more years of arduous knight-gallantry before Parsifal learns how to stand strong in the presence of the Grail. He must earn the right to return to the Grail Castle, and his years of knight’s gallantry gradually strengthen him sufficiently so that he can ask for a second entrance.
During this time, Parsifal leaves the Learning Phase. Although he cannot determine exactly when the transition happens, the progression is marked by his describing new, innovative ways to save damsels, slay dragons, and right the worst of wrongs. He is comfortable with knighthood and seems to understand its [flow 9]. He is in the "Knowing Phase." He knows how to deviate from the recipe to produce creations that are unique and spectacular. They become his contributions and legacy to his field.
Many here can relate to that wonderful part of knighthood. It is that magnificent period where we just "get it." We know Thoracic Surgery. We are comfortable deviating from the rules to produce innovations—challenges to the conventional wisdoms that define the standards of our field—and from this, we create change and progress. Our innovations are transformed by the energy of "the flow" into solutions that no one has thought of ... yet.
Parsifal has been in the flow. He has made so many conquests that he is now a legend. He has transformed the way of knights by his innovations in Dragon Slaying, Damsel Saving, and Wrong Righting, and has in fact been elected as President of the Sovereign Tribunal Serving All (STSA). A cortège of pages from the Castle summon him to appear before King Arthur to be proclaimed the greatest knight ever. I need to mention that this is not a story about me—it is a story about you. Each of you. And it is about all of us.
Parsifal, with his sword of experience now shining brightly, has achieved more than any other knight in Arthur’s court. How can he be the innocent fool destined to ask the Grail question? Surely we must have him confused with someone else.
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The Soul Search—Reconnecting to the Call |
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 TopIntroductionPrologueInnocenceHearing the CallTrainingBeginningThe Pursuit of Learning,... The Soul Search--Reconnecting to... Enlightenment and TransformationEpilogueFootnotesAcknowledgmentsReferences |
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In the midst of the great ceremony, extolling all of Parsifal’s worldly accomplishments, at the very height of the 3-day festivity marking the STSA celebration, a most hideous damsel appears and puts an instant damper on all the celebration [7].
Her mission is to present the other side of the coin at the festival, a task she accomplishes with surgical precision. She recites all of Parsifal’s sins and stupidities, the worst being his failure to ask the healing question in the Grail Castle. Parsifal is humbled and left silent before the court that only a moment before had been praising him to the sky. Just when we think we have arrived at the height of knowing, just when we think the journey is over, we find out it has only just begun.
The opportunity to transform requires that we get to this point.
With the certainty of sunset, the Hideous Damsel walks into a man’s life just when he has reached the apex of his accomplishment [7]. We need to expect her.
Thoracic Surgery has needed to expect her.
Accomplishment is not protection against meaninglessness. The accomplished man is most likely to ask the unanswerable questions about his worth and the meaning of his life. The Hideous Damsel carries anguish and doubt—the reflective, critical feelings that visit any intelligent man at mid-life [7]. She reminds Parsifal that to move forward, he needs to confront the most perilous "knight" of all: the "Dark ‘Knight’ of the Soul." This battle is waged late in the evening, as he lies awake, wondering what life has all been about. The angst usually comes around 2 AM, after the pager has gone off and you can’t get back to sleep. This knight has brought down many heroes.
The savor of life has gone; unanswerable questions torment him. "What is the use of going to work? What difference does it make? What good is it?" He thought he was pursuing a life fit for a man-god. He has been saving lives, destroying the demons of disease, and creating innovations that have transformed his world, but as it turns out, these are just human pursuits. He knows in his heart he is not a god. What was he thinking when that first vision of that fabulous knight swept him away? Being a knight isn’t what it used to be. The world is changing. In fact, there are others out there doing the work he used to do. He is feeling obsolete. Why? Woman pleases him no more, his children are gone, and vacations don’t soothe any more. Just when he begins to have the time and the means for a pleasurable life, that goal feels meaningless.
This is the work of the Hideous Damsel.
Like many adversaries in life, the Hideous Damsel also brings a gift. Look at this image of the Hideous Damsel (Fig 2). It demonstrates the conflictive nature of "reality" that can exist depending on our perspective. As you look at this picture, some of you may see the old woman. For today’s purposes, you see the Hideous Damsel. And some of you may see only the young woman. Some of you may not see either, and a few of you, with discipline, can see both simultaneously.
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After the Hideous Damsel’s visit, Parsifal retreats into the "foul rag and bone shop of the heart " [14], the dark place where authentic work is done. Not the fancy, spectacular work of the knight who illuminates the dark with a gleaming lance. No, this is the work that traces back into the geography of the soul where there is no map, and without courage and vision, a knight could get lost and never return.
Perfection is no longer important, but consciousness is.
If anyone is humble enough and of good heart, he can find the interior castle and the Grail solution. The solution is not "out there." Parsifal has had the arrogance beaten out of him by 20 years of fruitless searching, and he is now ready to reenter the castle and ask the question.
Just down the road, turn left, and cross the drawbridge.
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Enlightenment and Transformation |
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TopIntroductionPrologueInnocenceHearing the CallTrainingBeginningThe Pursuit of Learning,...The Soul Search--Reconnecting to...Enlightenment and TransformationEpilogueFootnotesAcknowledgmentsReferences |
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Once again, the Grail comes before him, but this time the humbled Parsifal is prepared and he asks the question that is his contribution to mankind—my contribution to you today: What is it?
Today, in this moment, embrace the Parsifal dream that is in each of you, that part that knows you are here to make an important contribution to this world. And ask the question:
"Whom does the Grail serve?"
Remember that question. You will need it someday.
What a strange question! However, the question is the most profound question we can ask:
"Whom DOES the Grail serve?"
In the Learning Phase, we think we know the answer and are quick to respond [7]:
I am the center of gravityI work to improve my life
I am working toward my goals
I am increasing my equity
I am making something of myself
In the Knowing Phase, where we are self-actuated and think we are approaching our dreams, we answer the question again, only differently [7]:
I am searching for happiness
Which is to say that
I want the Grail to serve me.
I have earned it. After all, haven’t I been a magnificent knight? Look at all I have done.
No sooner is the question asked than the answer comes reverberating through the Grail Castle halls:
"The Grail serves the Grail King"
Which means that the Grail (our vision) serves something greater than ourselves.
The Grail doesn’t serve us.
We serve the Grail.
The wounded Vision King rises at this moment and sings a wondrous song of triumph, power, and strength.
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Epilogue |
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We, like Parsifal, have been on a wondrous quest. Wearing the full accoutrements of our knightly trade, we have rescued, combated, and righted. We have committed ourselves to the glorious realm of thoracic surgery. No one can take from us our gifts, our talents, our skills, and our knowledge. And with our swords of experience we win many battles. Our profession gives us great rewards, and we have confused those rewards with happiness and success.
The Vision King and the entire Grail Kingdom are suffering, and we want to restore it. To what it was? Once wounded, there is no healing force that can eradicate a scar. Healing occurs through the regenerative power that submits to, accepts, and welcomes transformation.
Some of us are in the exhilarating "learning phase." Enjoy what you are learning. Engage in it and remember that learning is difficult. Learning requires listening and a willingness to ask questions and be open to exploring new possibilities. To be a lifelong learner is to invite struggle and change [15]. There is little I do today that I learned as a resident or young surgeon, and I suspect that is true for many in this room.
Some of you have entered the "knowing phase," and you have the confidence of the greatest knights. You have learned and are now in the flow of the field. Your creativity and genius will help change our world. Let go of what was and help us understand what can be. The Vision King cannot die. He needs the rejuvenation that comes from your imagination and from your dedication and courage to continue the Grail quest.
And then there are some here who are ready to enter that final phase—the "serving" phase—and it requires transformational work so that we can ask the question:
"Whom does the Grail serve?"
And there are sure to be other questions.
We must to remember to ask questions and not worry about finding answers. They will find us, as long as we invite change. The answers come from engaging in the process of exploring solutions we have never thought of before. The Vision King is healed by the courage it takes to do the asking, not by the answering.
Each phase is important and should be treasured: the energy in the learning phase; the creativity and accomplishment of the knowing phase; and eventually, the salvation from the transformational serving phase [2]; not in some aggrandizing way that serves the self and that tries to keep change from happening, but in a way that creates thoughtful and visionary leadership for those who follow. Those who follow need that from us: permission, inspiration, and courage to create change [15].
We need our learners. We need to support and nurture them. Identify them, those young Parsifals, those of you in the knowing phase, and give your mentorship graciously, compassionately, and genuinely to them [16–18]. They need you, and you will need them if our profession is to have a bright future. Be their Gournamond not because you have to, but because you can. They will someday enter the Grail Castle behind us.
And for those in the learning phase, do not be impatient. You will learn. I have seen so many young surgeons who, just like me, wondered if they would ever conquer the challenge of a difficult operation or the concepts of a difficult problem. I can assure you that you will. The length of the knightly journey is different for each of us. I cannot emphasize enough how much more you will enjoy the learning phase if you can find compassion for yourself when learning includes struggle [11–13].
There is a thin line between learning and knowing. I am not certain when you become an accomplished knight, but at some point, it becomes apparent to you that you are. The transition is not definitive, because there are times that learners are knowers and times that knowers are learners. Isn’t it wonderful that life works out that way? We never leave the learning phase, but we begin to incorporate more of the knowing, and we are surprised at what we see that we did not see before, like the optical illusion in Figure 3A. Once I tell you that there is a cow in Figure 3A, you may never see it any other way. Knowing is not incremental, it is transformational. Some of you can see this cow and some of you cannot. I include this image to make a point. If you have not seen the cow, then turn the page, look at the next illustration (Fig 3B), and then reexamine the photo on this page. We continue to see things as only we can, until we are suddenly able to see them differently. And once that happens, there is no going back—once you learn, you know.
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The longer we are in the field of thoracic surgery, the more we understand it. It is a gift "to know" and to be able to do what we can do for another human being. You have worked hard for that and I wish for you a conscious appreciation of yourself. The sacrifices you have made. The anxieties of enormous responsibility handled with progressively increasing poise.
And for those of you who are in the creative, flowing energy of the knowing phase, prepare yourself because the Hideous Damsel knows where you live.
Our happiness, our true contentment comes when we realize:
It is not the Grail that serves us. We serve the Grail.
The Hideous Damsel will ask us to question our belief system. She will have us challenge our patterns and look for new paths. She will remind us of the inexorable necessity for change. We cannot let ourselves feel too satisfied, or too dogmatic, or too tired, or too old to do this. This is where the important work for the future—our future—is done. The noted historian Arnold Toynbee once wrote: "Nothing fails like success" [10]. The old patterns will not work anymore. They never do for the visionary pursuits. And thoracic surgery is a visionary pursuit.
The Grail represents vision, transformation, and enlightenment. We can seek the Grail throughout our lifetime and not find it until we know where to look [19]. Finding it requires connection to that unique individual called by your name. There is no one else on this planet exactly like each of you [12]. Each of you carries within you some spark, some special way of being and of seeing that yearns to be unleashed from the old rules that may not serve anymore. It is hard work connecting to that unique and powerful force called "self." It takes courage, insight, and will. But that is the treacherous pathway to finding the Grail.
Learning, knowing, serving—what each of you does everyday—takes courage. The fact that we understand courage allows us to enter the Grail Castle and restore our vision. We need to ask, with a fresh, beginner’s mind, the questions about who we are and what we want [20].
Ralph Waldo Emerson pointed us in the direction of the Grail search when he wrote:
What lies behind us and what lies before us are tiny matters compared to what lies within us.
The solutions to so many problems aren’t "Out There." They are much closer. They are "In There." In you. In each of you. In your ability to embrace and celebrate who you are, what you learn, how you create yourself. It is the parallel process for creating transformative change in thoracic surgery. As you engage in one, you will find new paths in the other.
We have great potential energy in thoracic surgery. This energy exists in our potential to imagine, synthesize, and transform ourselves.
Again.
The Grail Castle is waiting for you to reenter. Unlock the potential of that gift that is inside each of you.
The road inside us presents a daunting path.
But what we want is just down that road, a turn to the left, and across the drawbridge. And be careful, because the drawbridge will brush the hooves of your steed as it closes.
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Acknowledgments |
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I am extremely grateful to Donna Dermond, who skillfully and gently guided the development of this parable so that I could express my unusual message in a manner far beyond my own capabilities.
I am indebted to Susannah Lai and Scott Eman in the Doernbecher Children’s Hospital Media Lab for their extraordinary abilities and imagination in developing unique auditory and visual effects to accompany the presentation of this address at the meeting.
This story is dedicated to the enumerable people who have taken time and interest in helping me learn and grow. They comprise an entire spectrum of health care providers, patients, colleagues, and friends (some of whom were present at the meeting) that I have been blessed with in this life.
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Footnotes |
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* In this story, the Grail is a metaphor for vision and transformation. It is not intended to have religious implications of any kind. This is meant to be a story for all of us who aspire to leave something behind that changes the world. The Grail (and the quality of our search for it) is the container for that dream. 
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References |
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