Practicing Mindfulness in Surgery: A Discussion with Phillip Pierorazio, MD, Creator of “Operate with Zen”

Phillip Pierorazio, MD, is the chief of urology at Penn Presbyterian Medical Center and a professor of surgery at the Hospital of the University of Pennsylvania, in Philadelphia, Pennsylvania. Beyond clinical work, Dr. Pierorazio has contributed extensively to research in urologic oncology. He is a renowned lecturer on physician wellness and is the creator of the popular podcast, “Operate with Zen,” in which he discusses a scientific and data-driven approach to mindfulness in medicine and surgery.

David Ambinder (DA): Dr. Pierorazio, it is a privilege to be able to discuss with you a topic that you have given many lectures about—and dedicated a podcast to—mindfulness and wellness. Can you tell us about mindfulness and what it means to be “mindful” as a surgeon?

Phillip Pierorazio (PP): The basic principle of mindfulness is being present and in the moment. There are so many ways that mindfulness is incorporated into surgery. The term I use to describe it is “intentionally purposeful.” Our lives are so busy, but if we can be slightly more efficient and productive in our day—and gain some more time—all of a sudden, we can be exponentially happier and more productive, because we’ve created space for the other things we want to do.

The way to be mindful or present in surgery is to think only about what you’re doing at the moment and get everything else out of the way. The easiest place to do this is in the operating room. We’re all present and focused on that patient and their care. We have gotten rid of our phones and other things, and we are focused on the moment.

DA: What inspired you to learn about and pursue mindfulness?

PP: Briefly, when the COVID pandemic started, I had a lot of free time. I started thinking, “What could I work on myself that would be better?” And it started honestly, simply, with needing to be more physically flexible. I felt that my back and feet were hurting when I was operating, and so I picked up yoga and started reading about mindfulness practices, and how and why meditation and yoga work.

It was exciting for 2 main reasons: first, I picked up new things and learned how to get better, and second, it affirmed a lot of good behaviors I was already practicing. And, looking back, it affirmed many things my mentors do well.

DA: In your podcast, you discuss Dr. Walsh and how he inspired you greatly. Who were some of the other mentors who inspired you?

PP: Dr. Patrick C. Walsh (chairman emeritus of the Brady Urological Institute and a professor of urology at the Johns Hopkins School of Medicine) was incredibly present in the operating room. I learned presence and intentionality from him. Another great mentor was Dr. Mark Schoenberg, who was a member of the faculty at Hopkins when I was a resident, before he moved to New York. At a time when it wasn’t acceptable or appreciated, Dr. Schoenberg would ensure he got out of the hospital to spend time with his family and to exercise and maintain physical wellness.

A third mentor was Dr. Jim McKiernan, who is now the chair at Columbia University Medical Center. He was one of my mentors in medical school, and I give him a lot of credit for my academic success and productivity. He taught me how to be academic and really gave me a love and passion for it. He was one of the busiest junior faculty members, but when one would sit with him, he was fully focused on the person in front of him. He set an example of presence in the moment and imparted passion and enjoyment about the academics of urology and medicine.

DA: What made you decide to start the “Operate with Zen” podcast?

PP: Before I started podcasting, I knew very little about podcasts, except the murder mysteries I listened to. I considered putting my thoughts together about mindfulness in surgery. I considered what the right format would be. In 2021, the right format for this was a podcast, specifically the ability to talk through these thoughts, and if it benefited anybody else, that would be a huge positive. At a minimum, it was a way for me to organize and collate the ideas I was thinking about.

As the podcast progresses, I learn more, and in the more recent seasons I have begun to trade in a fair amount of monologue for interviews and conversations with colleagues in urology, surgery, psychiatry, and other specialties, to see how and what we can learn to get better as surgeons. That has been an exciting and enjoyable aspect of the podcast.

DA: You quote many sources and evidence for the things you discuss in the podcast. Why do you emphasize this so much, and how do you do your research?

PP: It’s important because we are scientists, and we want to know why. It was important to understand the science behind the topics and to share the data, limitations, and current investigations.

Furthermore, I’m well-trained in urologic oncology, but not so well-trained in mindfulness. I’ve picked a lot of this up independently, and many ideas are not original. What is original is the way I try to put things together and apply them to surgery, but I’m not a mindfulness “expert” beyond what I try to do in my own life. So, putting forth and crediting the experts is an important part of this.

I find many sources by reading. In fact, as part of my wellness practice, I carve out time and space to read things I enjoy. I try looking up references and finding original source papers. There are some tremendous source articles on wellness and mindfulness; for example, the original Anders Erickson paper on the 10,000-hour rule is a phenomenal read.

DA: How do you think practicing mindfulness and awareness affects wellness? Or, on the flip side, how is a lack of mindfulness and wellness related to stress and burnout?

PP: The biggest aspect of the podcast is opening a channel for people to normalize and talk about these things. In my opinion, every residency should have a formal or informal wellness curriculum. We need to emphasize healthier living, not just in the operating room, but also eating habits, physical activity, and regular doctor and dentist visits for health maintenance. We are normal people who just happen to work in medicine, and we shouldn’t be neglecting ourselves because of the profession.

DA: How do you think this translates to the operating room specifically?

PP: One of the real keys is mindset and being present in the moment, focused on what we are doing. There’s physical well-being in the operating room too, taking care of your body. Surgeons are supposed to have 30-year careers. We have a physical job, and we need to take care of our necks, backs, core, and shoulders. Building in a physical wellness aspect is important for career longevity.

If we set ourselves up with a good foundation of physical wellness, good nutrition, sleep hygiene, etc., it allows us to be more efficient, with more energy, and enables us to persevere through many of the challenges of a life in medicine.

DA: In addressing young urologists just beginning their careers, what are 3 key pieces of advice that you would offer?

PP: The first thing I would say is, take time to be thoughtful about your short-, intermediate-, and long-term goals. It’s important to write them down and to have metrics that you can use to evaluate yourself.

The second thing many young surgeons struggle with early in their careers is identity, which can translate into career dissatisfaction. Identity conflict can include personal conflict (e.g., wanting to be a great surgeon in a specific area, but not being well-trained for it), or it can involve an institution (e.g., wanting to pursue academics when that is not the vision of the leadership where one works).

It is important to spend time investigating yourself to determine who you are and what you want to be. If the vision isn’t matching clinically, then attempting to reconcile your work and your vision is appropriate; often these factors can be resolved. This extends into other areas of life as well. For example, if a person says family is the most important thing in their life and, “My children are my number one priority,” but the first thing they do on Saturday morning is wake up and play 6 hours of golf, well, that individual may not be walking the walk. If you really love golf, then find the time for golf, but don’t say your kids are number one. It’s important to figure out who you are, where you want to be and your identity, and align your life to that.

The last piece of advice is maintaining physical health and keeping well-being as a foundation. Life is hard. Whether as a resident, attending, or any job in medicine—it is going to be hard. That is the nature of what we do. But having a good foundation in grounded physical well-being and health makes those things easier and it makes your goals much more achievable.

David Ambinder, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology.