Purpose
To examine the interaction of surfer culture with medical culture in order to elucidate how the two cultures interact and affect the lives of physicians who are also surfers.
Introduction
Surfing has been described as a combination of art, sport, and spirituality, which has led to a unique culture unifying surfers.15 Marilyn Edwards, editor of the Wahine surfer magazine, describes the culture of surfing: “Surfing is not about achievement. It is about balance, blend and unity. It is about being a part of, not about dictating or ruling it. The Zen of surfing is about being mindful of the energy you are joining forces with, not conquering it.” Dealing with life and death situations on a daily basis results in a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Hence, physicians have been tied to greater compulsiveness, guilt, and self-denial than the general population.5 While these cultures are vastly different in their value systems, there exist people who take part in both cultures. This study explores the interaction of surfer culture and medical culture through interviews with these surfing physicians.
Methods
I contacted the Surfers’ Medical Association and European Association of Surfing Doctors describing my research. They emailed out to their members information about my study and participants emailed me if they were willing to be interviewed. Those who agreed to participate were interviewed via phone, Skype, or in person between June 2014 and August 2014. The interviews were recorded after oral consent was received. One-on-one interviews were then be conducted in order to gain an understanding of each participant’s experiences with both surfer and medical culture and how surfer culture has impacted their sense of purpose, stress levels, and work/life balance. The interviews were semi-structured following an interview guide. The recordings were de-identified immediately after the interview in order to preserve the participant’s confidentiality. The interviews were transcribed and the transcribed interviews were coded and evaluated in order to analyze the impacts medical and surfer culture had on one another. The coding process consisted of identification of major themes using Atlas-TI, a qualitative software package designed to assist in qualitative data analysis. Quotes illustrating the various themes were recorded.
Results
Sixteen American physicians and six European physicians were interviewed. They were asked about the relationship between surfing and medicine in their lives and how the two affect one another. Additionally they were asked whether they felt to need to hide one of their identities (surfer/doctor) while participating in the other culture (doctor/surfer).
Content analysis generated 4 major themes: Balance and Perspective (100% American physician interviews, 100% European physician interviews), Mindfulness & Exercise in Nature as Stress Relief (100% American physician interviews, 100% European physician interviews), Increased Compassion and Reduced Burnout (87.5% American physician interviews, 100% European physician interviews), and the Stigma of Surfing in Medical Culture (68.8% American physician interviews, 16.7% European physician interviews). 81.3% American physicians interviewed do not hide their identity in either culture, but some (27.3%) mention being more discreet when they were earlier in their training.
1. Balance and Perspective (100% American physician interviews, 100% European physician interviews)
He’s really psyched to surf!
All participants described surfing as a means of adding balance and perspective to their lives. Many participants viewed surfing as a counter-balance to medicine. One physician quoted,
“I think surfing probably is a way to relax and escape some of the stresses of being a physician. It’s a stressful job. I think you need ways to get away from that constant stress and workload. It’s a way to relax and focus on something else and focus on exercise and yourself. Be away from yourself, be away from a pager, be away from those responsibilities for a little bit.”
Similarly, surfing brought valuable perspective to many physicians’ lives. One physician states,
“I think when you’re a surfer, nature is more powerful than you are. Life is not all about being a badass doctor. I mean you have to take it seriously and bring your A-game all the time. But I mean you’re not in charge all the time. That’s what surfing’s good for. I think it brings you humility and confidence. It helps you acquire humility which I think is a good thing and confidence, you’re like I got hit down really hard in Huntington Beach and I’m alive and things aren’t really bad. I can handle this. That kind of thing.”
The combination of offering balance and perspective gives surfing the unique ability to bring the feeling of a fresh start to participants. As one physician states,
“Like I say, it’s almost like a restarter or refresh button. Number 1, I’m seeing patients in the morning and I’m thinking oh I’m going to get out of here and get into the water. I leave here and then I go down to the beach and it’s just you know the complete opposite. I don’t have to deal with anything or try to help anybody or anything like that. I’m just in the water thinking about the ocean. And it’s that release and the ability to just drop from your mind everything else you have to deal with patients and everything and come back to it. So I think it’s just that, it’s almost like a yin and yang that you’ve got 2 completely different things, that allows you to escape the stress of dealing with patients. You know it’s the not thinking about the office. The physical exercise. Or the concentrating on something else. That’s the escape.”
The feeling of being reset is important to balance the demands of being a physician:
“It’s a positive thing for my work-life balance. I’ve always wanted to maintain being able to surf and go to the beach. Just getting in the water, forgetting about what I have going on at work that day. It’s just something completely different and not an escape, because it’s not that I hate my job. I love my job, I love what I do. But there are a lot of demands and it’s intense. In surfing, there are no demands other than me being in the water. I describe it to my father-in-law as hitting the reset button, you get in the water and you get out of the water and you’re reset.”
Multiple participants described the balance surfing brought to their lives as beneficial to their career and patient care:
”I think more and more people are realizing that you need a life, to be a good physician, you need a life. And you need to be happy. And if you’re very unhappy with yourself or your life, you’re not able to bring as much to the table in the medical field. And most people that I know are happier when they’re balanced and they do hobbies outside of work. So I think hobbies are a very good thing. And I think surfing is a great hobby. It’s thrilling, it’s good for you, it’s relaxing, it’s a combination of yoga and athleticism and being social out there if you want.”
2. Mindfulness & Exercise in Nature as Stress Relief (100% American physician interviews, 100% European physician interviews)
Surfing allowed participants to be present and physical in nature which released the built-up stress related to their work. One physician describes why surfing is so beneficial:
“I think there’s something unique in surfing in that it obviously gives you the benefits of physical activity, it gives you a closeness to nature, it appeals to our sense of restlessness because there’s a sense of expiration. You’re searching for new waves, you’re going places. It’s the whole experience of going to find waves and then riding waves. It’s exciting. It’s adventurous. It’s kind of the sum total of all those things I guess for me.”
Another physician touts similar benefits:
“For me, it’s an all body or complete body exercise. It’s an activity that I can never perfect and it is also a reconnection with nature and the basic of life and not technology expectations and everything else.”
Many participants described mindfulness as a benefit of surfing:
“I think one of the benefits of surfing is that it brings you back to the present moment because if you’re surfing and riding a wave you have to be in the present moment so that’s a very valuable skill or thing to learn in life and it helps you in medicine too. So if you can just come back to yourself in the present moment, you can deal with you a lot of things that are happening around you. These days you hear the use of the word mindful. It’s relevant. It makes you pay attention to the things happening around you and not what’s going on tomorrow or yesterday. You just deal with what’s right in front of you at any given time with the resources you have.”
“I think growing up surfing and the focus you have in the water, I think that actually translates over. I think it’s always allowed me to operate well in a dynamic situation. When you’re surfing, you’re out there, you’ve got the waves, the waves are moving, you’re constantly thinking about what position to be in, there are other people in the water you have to think about, everything’s constantly moving. It’s very dynamic. I know that sounds sort of hokey, but it’s true. It sounds like gosh, that sounds stressful. But no it’s relaxing. You gotta stop and focus on that. I think the other thing too, it has taught me to relax when things are moving and constantly in flux. When I’m in the ICU or the pediatric ICU, taking care of a sick kid, I think that dynamic situation I was always in while surfing helped prepare me for being in those situations where there are a lot of moving parts going on. There’s a lot of things changing at the same time. It’s allowed me to sort of get through that in a calm and collected manner. Maybe that’s just my personality, but you know I can’t separate it from surfing. I think it’s also partly due to the surfing and being out in the water.”
Participants described the mindful state as not only useful, but enjoyable:
“When you’re really focused, when you’re paddling and take off on a wave and you get to that state when you’re really focused, when everything seems to be alright and it’s more of a feeling. You really feel complete and in the moment. That’s a really good feeling. It’s not just a vision, it’s everything comes to one. And I think once you have experienced that feeling, you want to reach it again and again. And what I noticed is you can also reach not the same state but nearly the same state in different situations in life. Like you can also reach it when you’re really focused in theater, or you really concentrate on some difficult thing like suturing some vessels together or nerves or something. You’re really focused or.. it’s not the same flow state but it’s nearly the same.“
Many participants describe a state of flow while surfing:
“You reach a flow state and optimal experience, if you’re just doing something that’s completely within your realm. If you’re constantly aspiring to things that are just out of reach but accessible, you’ve got a shot at being happy.”
Another element adding to the balance and perspective benefits of surfing is the physical exertion:
“I think when you’re surfing, you get out on the water, when you’re surfing you kinda don’t think about anything else. I mean you can sit there and think about things, but once you catch a wave or are looking at the waves, you’re trying to figure out what to do, that’s kind of taking up your mind so your mind releases from everything else. On top of that, physical fitness aspect of it.. you know it’s a help too and all the endorphins and everything that are released when you exercise. You know, that’s all a big part of it.”
One physician describes the physical benefits as empowering:
“So basically you lie on the beach and you’re exhausted and sunburnt and sore and actually happy as can be. It gives you not only physical power because it builds up your muscle but also psychologic power. You catch that wave today and it was really difficult but you made it… so you know, little challenges that give you a positive aura.”
The mindfulness and physical exertion in nature was the powerful combination quoted to give surfing its unique ability to add balance and perspective to the physicians’ lives:
“I think that it’s probably one of the best ways to destress, you know being in the water, and just connecting with everything in nature. Just kind of let things go. It’s always a good way to clear your head. If I haven’t been in the water for a while, I’ll feel it you know and I’ll miss it. I need that. It’s therapy I think.”
One physician describes the power of being in nature in gaining perspective:
“Well, basically it gives me a lot of fun. It makes me part of nature itself. Struggling with water makes you try to not only part of nature, but it tells you where your part in nature is. You’re just a little little part and you don’t have to take yourself too seriously. It gives me a lot of fun and calms me down when I am angry or exhausted and even though it’s a pretty tough sport, it gives you a lot of power back.”
3. Increased Compassion and Reduced Burnout (87.5% American physician interviews, 100% European physician interviews )
Don’t drop in on me.
Surfer doctors reported being more compassionate to patients and coworkers with regular surf sessions and describe surfing as a prevention of burnout through “resetting” or restoring balance to their lives:
“I think that I made a point to incorporate surfing in my life in order to make that work-life balance. And I knew that when I went out even if it was just to catch a couple waves if that was all the time I had. Or to surf for a whole afternoon. That I would come away from that just absolutely overjoyed. And smiling. And you know, physically and emotionally really happy. And I knew that would impact on my practice of medicine. Because that was what I would carry back to the office. Or carry the next day when I would go see patients. Take care of people. Yeah.”
Surfing allowed many physicians to bring the peace and joy to their practices:
“Surfing makes me much more fluid, and calm, and empathetic, and patient. I kind of found a weird niche for myself, it was really validating to feel that they appreciated what I brought to the table. I’ve been told I’m the most balanced, even-keeled doctor they know. And I think the surfing helps with that.”
The balance and joy they felt brought them to be more compassionate to coworkers as well as patients:
“It’s changed me, I think for the better, and a sense of feeling more balanced and happy with myself and you know, interested in other people, my patients, and other people I meet in the hospital in terms of who they are and what makes them happy and what makes them tick and that sort of thing.”
And many described surfing as a good way to prevent burnout:
”I don’t know if I can narrow it down to a session. It’s not like I’m horribly stressed and depressed and I got to go out into the water and I go into the water and I’m like OH I’m much better! It’s more of a general ongoing thing. Like I was just saying if I have to be away from the water for any extended period of time or I can’t do the things I like to do for any extended period of time and still have my typical stress levels associated with work I would get depressed. I’ve had… I can get fairly depressed in a situation like that.”
One physician explores the psychology behind this phenomenon:
“In the most simplistic way, when I go surfing and I come into work, my primary cognitive structural thought is I’ve had the best part of my day, I’ve achieved everything I could hope to achieve. Everything else is icing on the cake. So that’s the first one. It’s very hard for me to feel bad afterwards. It’s not just bad, I feel very generous afterwards. If a parent of a patient calls me and starts yelling at me and is like you did this, you did that. In another situation, I might feel very burdened and put upon and attacked. In this situation, I’m able to say, wow, you seem angry. That’s fair. I get that. Let’s slow down. How can I help you feel better? What can I explain to you? I think a psychiatrist should be able to do that all the time, but if you don’t have the bandwidth and the reserves and the feeling that your needs are being met, you can’t really do that. You know this zen mode of you seem upset, I think I can understand that. So I think that has an immediate after effect of reserve and calm…”
Another physician describes why being balanced allowed greater empathy in their practice:
“What I recognize is when you’re a stable personality and you’re really calm and you’re just happy with the way you are and the way your life is, you can give a lot a lot to patients. I think medicine is all about sharing emotions and necessarily if you’re feeling not well, you can’t really be empathetic, you can’t really share emotions with people. They are just getting on your nerves. As surfing is a tool to calm you down and bring you back to who you are and rearrange your world a little bit. It necessarily gives you more power and more strength to deal with other people’s emotions.”
4. Stigma of Surfing in Medical Culture (68.8% American physician interviews, 16.7% European physician interviews).
68.8% of American participants describing a stigma surrounding surfing in medical culture. Most participants live in cultures that accept surfer culture or simply choose to fight stereotypes by being open with their identities as surfers-doctors in medical and surfer culture:
“Maybe not hide is the right word, but I think there is this perception not just in medicine, but in general that surfing culture and surfers are not conducive to intellectual pursuits. There’s a general stereotype that’s been around even since the 80s and before then particularly with movies like I think it was Fast Times in Ridgemont High where the prototypical surfer was somebody who was not very eloquent or very smart. So I think there still is that persistent stereotype and it’s not something that a lot of physicians promote themselves with or are very outspoken about because of that perception and how that can be seen as maybe a slight negative in that regard both in the eyes of their colleagues and their patients. But it’s not something that I feel that I or other physicians actively hide either. A lot of my colleagues know that I surf and know that I’m passionate about it and I think once they get to know me at work, I don’t feel that that stereotype is something that they really apply to me.”
81.3% American physicians interviewed have never hid their identity in either culture, but some (27.3%) mention being more discreet when they were earlier in their training:
“That’s such a good question. I feel when I was in medical school, I felt like I had to hide it. Since I was in [City], a lot of the professors, even the students, would say “Oh he’s just a surfer” and make fun of it–a Disneyland fairytale, where we were from–from California. So I felt like I needed to hide it a bit when I was there. And yeah just people in general are more conservative out there. Compared to laidback California. But now that I’m in medicine, when I’m around big surfing events, most people know who I am now, so it’s not uncomfortable. If I’m just wearing a hat, I’m in surf clothes, most people don’t believe I’m a doctor. So I usually don’t have to even say anything. But now I’ve taken care of so many people in the area, I can’t go anywhere without people recognizing me. So it’s been a lot of fun now. Last week when I was at the US Open, everybody, the whole medical team, we just all work well together. We’re all different specialties, we work with massage therapists, physical therapists, all of us really get along well. There’s no ego battle taking care of people.”
Fewer of the European physicians interviewed describe a stigma surrounding surfing in medical culture, but 16.7% describe a stigma and would consider hiding their surfer identity while early in training:
“I would say I would have had I started medicine when I was younger. For example, when I first went to university and studied engineering and started working, I was like 21 years of age and I kind of didn’t really tell anyone. I kept it a secret because I felt it wasn’t seen as serious and all these things. Whereas nowadays because I’m a little bit older, when I started working as a doctor, it was maybe 10 years later and I was 31 or so. I was more confident in myself and I think I felt.. I just didn’t give a damn about what people thought. The fact that I surfed? I had no problem saying that. I think it was more an issue of self-confidence. I felt more comfortable in my own skin and I was happy to say whatever I enjoyed and I don’t care what people think of it to be honest anymore. But probably when I was 21, I was a bit less confident in myself and probably a bit more wary of letting people know for fear they would see it as not a serious activity and therefore people would think I was not serious about my job, which was not the case. It’s a thing about things we learn as we grow older, you know? Self-confidence thing, really.”
Discussion
Surfing has been shown to be a positive impact on the well-being on youth populations as well as veteran populations.4,6 However no studies to date have explored the impact on surfing on physician well-being.
68.8% of American participants described a stigma surrounding surfing culture in medical culture. By definition, stigma consists of an attribute that marks people as different and leads to devaluation and is dependent both on relationship and context because stigma is socially constructed.9 It is not surprising two significantly different cultures would result in stigmatizing of the culture and 27.3% felt the need to be more discreet about their surfing identity in medical culture. However, participants described because of the differences in the cultures’ value systems, surfer culture “reset” the participants, allowing for significant improvement in work-life balance and increased energy and productivity when returning to medical culture. Medical importance places much of the responsibility and power in the hands of the provider whereas surfing undeniably the participants must bow to the power of nature. The perspective provided by surfing allowed participants to restore balance and avoid counterproductively swinging too far into self-judgment, self-sacrifice at the expense of their health, and allowed for restoring of personal vulnerability.
The participants state that the unique combination of nature, mindfulness, and exercise are the key to surfing’s powerful balancing effects. Mindfulness has been shown to reduce psychological distress and increase positive emotions in physicians.1,12,14 Similarly spending time in nature has been shown to improve mental health.3,7,11 In fact, spending time in nature has been shown to improve cognitive functioning and mindfulness further supporting the idea of synergy among these modalities.2 Lastly, exercise has been linked to improved mental health provided participants do not overtrain.10 There has been some evidence that exercise in natural environments provide increased mental health benefits than does exercise indoors.16 The combination of all three modalities allows for greater perspective, restoration of balance, “flow” state, and synergy.
The participants also discussed the joy surfing brought and the importance of fun and play for balance. Participants described greater productivity and compassion as a result of their increased happiness. Compassion fatigue is common among medical providers, and restoration of physicians’ compassion is crucial. Additionally participants described the joy of surfing as significant to preventing their burnout. Burnout has been described as damaging to both providers and their patients, reducing quality of care. Many participants describe surfing as crucial to preventing burnout and increasing their compassion.
The participants discuss the harmony and resulting synergistic benefits of being part of both medical and surfer culture. This qualitative study cannot draw causative relationships between surfing and medical culture, but the associations and themes discovered were quite apparent. This study offers way to further inquiry examining the effects of surfing on medical providers in a society where issues of burnout and balance are consistently brought to the table.
Acknowledgements
I would like to thank Joseph Carrese MD, MPH and Gail Geller ScD, MHS for their generous guidance as part of the Medical Humanities program, Ed Bessman M.D. and Mary Chang M.D. for their mentorship, and the Surfer’s Medical Association and the European Association of Surfer Doctors for their cooperation and wonderful support.
References
- Amutio A, Martínez-Taboada C, Hermosilla D, Delgado LC. Enhancing relaxation states and positive emotions in physicians through a mindfulness training program: a one-year study. Psychol. Health Med. 20, . (2015). 720–731.
- Berman MG, Jonides J, Kaplan S. The cognitive benefits of interacting with nature. Psychol Sci. 2008 Dec;19(12):1207-12.
- Berto R. The role of nature in coping with psycho-physiological stress: A literature review on restorativeness. Behav. Sci. 2014;4:394–409.
- Caddick, N.; Smith, B.; Phoenix, C. The effects of surfing and the natural environment on the well-being of combat veterans. Qual. Health Res.2015, 25, 76-86.
- Gazelle G, Liebschutz JM, Riess H. Physician burnout: coaching a way out. J Gen Intern Med, 2005 Apr;30(4):508-13.
- Godfrey, Cath, MSc; Devine-Wright, Hannah, PhD; Taylor, Joe. “The positive impact of structured surfing courses on the wellbeing of vulnerable young people” Community Practitioner 88.1 (Jan 2015): 26-29.
- Grinde B, Patil GG. Biophilia: does visual contact with nature impact on health and well-being? Int J Environ Res Publ Health. 2009;6(9):2332–43.
- Huggard, P. Compassion fatigue: how much can I give?. Medical Education, (2003) 37: 163–164.
- Major, B & O’Brien, LT. The social psychology of stigma. Annual Review of Psychology, (2005). 56, 393–421.
- Paluska SA, Schwenk TL. Physical activity and mental health. Sports Med. 2000;29:167–80.
- Pearson D. G., Craig T. (2014). The great outdoors? Exploring the mental health benefits of natural environments. Front. Psychol. 5:1178. 10.3389/fpsyg.2014.0117
- Pflugeisen BM, Drummond D, Ebersole D, Mundell K, Chen D. Brief Video-Module Administered Mindfulness Program for Physicians: A Pilot Study. Explore (NY). 2016 Jan-Feb;12(1):50-4.
- Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014 Feb 17;9:23556.
- Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress Manag, 12 (2) (2005), pp. 164–176
- Taylor B. Surfing into spirituality and a new, aquatic nature religion. Journal of the American Academy of Religion. 2007(75. 4). 923-51.
- Thompson Coon J., Boddy K., Stein K., Whear R., Barton J., Depledge M.H. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ. Sci. Technol. 2011;45:1761–1772.