Archive May 25, 2020

Even If Our Mouths Were Filled

Josef Stalin once observed, “One death is a tragedy, a million deaths are a statistic.” 

In my last semester of undergraduate studies I took a class in World Politics from the recently retired chancellor of Pitt, Wesley Posvar.  One of the assigned texts began with the premise that Stalin, Adolf Hitler, and Mao Tse-Tung together were responsibly for roughly eighty-seven million deaths – many of them their own people, the very people a leader might be though to protect.  They were, in short, architects of megadeaths, many millions of them even prior to Herman Kahn’s invention of the term.  Ironically, Kahn created the word to describe the human cost of thermonuclear war, yet not one of these leaders ever detonated an atomic bomb.  They achieved their dubious distinctions by mass-producing human cruelty.

To a person with emunah, with faith, megadeaths like the Holocaust, the Ukranian famine, or the “Cultural Revolution” beg for a meaningful response.  Simcha Raphael, of the DAAT Institute, shares in a 2008 paper[i] that the origin of Jews praying for the dead, and ultimately of the Yizkor service, is to respond to the trauma of megadeaths (on the smaller scale of the ancient world) that befell the people.

Raphael places the earliest mention of such prayers in the time of the Maccabean revolt, when fallen soldiers were gathered and prayers offered for their souls.  The Yizkor service, however, rose out of the ashes of the First Crusade, when thousands of Jews in the Rhineland were slaughtered by the Crusaders, and was originally observed on the Shabbat before Shavout, the one just past as I publish this piece.  Coincidentally or not, this same season is the one that the United States of America has chosen to honor its fallen soldiers.  Later massacres in which mobs attacked Jews that they blamed for the Black Plague were commemorated in German Jewish tradition as Shabbat Shakhor, Black Sabbath, on Shabbat Hazon, the Shabbat immediately before Tisha B’Av. 

How well we, in Pittsburgh, understand this feeling now.  We have recited Yizkor five times so far since our own pogrom; the first time we did so was mere hours before another eerily similar attack happened in Poway, CA.  Our liturgy now includes a version of El Male Rachamim, God full of compassion, composed by Rabbi Daniel Yolkut in memory of our own martyrs.  The experience is transformed into one that would be very familiar to the originators of Yizkor in the Rhineland a thousand years ago.

Yet Raphael, citing another Pittsburgh rabbi, Solomon Freehof, highlights another, later purpose for Yizkor that will be equally recognizable to most of us: Yizkor as the family memorial service, when individuals dear to us are remembered, communally and yet privately, in the liturgy.  Plaques are unveiled, names of those lost in the preceding year remembered, books with messages of loss and longing printed.

The melding of these purposes into a single service is one of the clearest expressions of why Judaism will always stand against the Stalins of the world.  In the face of megadeaths, we struggle to return the faces to the individuals who have died.  We call them by their names, we each take on the responsibility of remembering those close to us, and we communally take on the responsibility of mourning those who have no one close.  A million deaths in Judaism is not a statistic – it is a million tragedies, a million individual human lives.

Years ago I observed a taharah, the ritual purification of a person’s corpse before burial, for the first time.  While I had been prepared for it, through reading the books provided by the New Community Chevra Kadisha and through a patient orientation by Rabbi Ron Symons, the experience was still transformative.  I went home that night and wrote in my journal about the extraordinary care this ritual requires, and also the extraordinary caring that motivates at least four individuals to interrupt their routines and lovingly, gently, and patiently provide a final kindness to a person who, in many cases, they never knew.  It cemented the holiness of each individual for me.

In particular my mind fell on the nine kavim of water, equivalent to three large plastic buckets, used in washing each met, each deceased person.  I thought through the macabre math problem of how many buckets, how much water, would have flowed had each of the Jewish victims of the Shoah been provided a proper Jewish taharah.  54 million kavim.  It evoked the words of the Nishmat Kol Chai prayer, said as a prelude to the morning service every Shabbat and Yom Tov: “Ilu pinu male shira kayam . . . ein anachnu maspikim l’hodot l’cha.”  “If our mouths were full of song as the sea (is filled with water) . . . we would not be able to sufficiently praise you.” 

Ilu pinu male shira kayam . . . ein anachnu maspikim liv’kot l’cha.  If our mouths were as full of song as the sea (is with water) . . . we would not be able to sufficiently mourn you.

We have once again entered such a time, a time when there is not enough water, indeed, not enough time, to sufficiently mourn.  Over the first few months of this year we saw bodies pile up on islands in the East River.  People in Wuhan, China, suspicious that the government was minimizing the death and disease in their city, suspected the truth because the crematoria were working overtime.  Philadelphia and other cities repurposed vehicles to double as morgue vehicles.

I fear we are also dangerously close to entering the mindframe that Stalin counted on.  Our obsession with statistics about coronavirus, with projected death and disease tolls, and with the political and scientific arguments about how to count them (and how worried to be about them, and whether they are somehow worse than dying of the flu), threaten to obscure the fact that each of these hundreds of thousands of people was a person.  It is a megadeath, and threatens very quickly to become an abstraction for many people, much as the Shoah has become for the current generation – complete with its own cadre of cynical deniers.

Yizkor Elohim et nishmoteihem – may God remember their souls.  Even as we grapple with how long to stay closed, when and how to reopen, how to have Shabbat dinner or provide comfort to people without hugging them or how to pray together from far apart, we grapple with remembering their individual souls. 

Begin by remembering names.  While many American Jews are descended from survivors of the Shoah, for many who are not, a name of a child with whom they “twinned” a Bar or Bat Mitzvah creates a connection to a real person who suffered that horror.  My two older children have learned to honor individual American veterans by going with their social studies teacher to plant flags on their graves each spring.  Honor someone’s memory in this current crisis as well: read the Medscape memorial list of healthcare workers who have died trying to save others from this disease.  Seek out families who have lost someone and offer comfort.  Be a source of comfort or financial support to the living casualties, to the people who live in fear as they go to essential work each day or who live in poverty because they have no work to go to.  Find a name of someone lost to the pandemic and say Yizkor for them – whatever their religion – so that they might not become a statistic.

Most of us will not be physically in synagogue this year, but if we were it would be time to do away with the superstition schmooze – the knot of people out in the hallway during Yizkor who still have two living parents and therefore “no one to say it for.”  Ilu pinu – even if our mouths were so full of song, there are more than enough names to go around.  It will take every one of this to ensure no one is forgotten.  Yehi zichram baruch.  May their memories be for a blessing.


Skin Out of the Game

A couple years ago a veteran dermatologist gave me advice that seems almost scandalous today.

“When you’re seeing someone who is embarassed about their skin condition, spend time really sitting with them. They may feel like they’re contaminated, stigmatized, ostracized or worse by the fact of how their skin appears. Don’t add to that. Examine them – closely. Without gloves if you can.”

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In Your “Hed”

The sanctuary at my synagogue seats 1800 people.  I have seen it filled to capacity twice, and spoke to the capacity crowd both times.  The first was at the funeral for my cousin, Dr. Richard Harris, in 2001, when I shared the story of the little black doctor’s bag he gifted me when I started medical school.  The second was November 3, 2018, when a grief-stricken community piled into the pews to mourn the eleven martyrs from the Tree of Life shooting. 

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Stitching a Safety Net

My guest op-ed from the Pittsburgh Jewish Chronicle from March 26th, 2020. Sometimes the heroes can’t do it alone, and sometimes even the people who feel most helpless are doing more than they can imagine. Like Neville Longbottom in the first Harry Potter novel, perhaps we will be the ones whose ten points for courage standing up to our friends and family will make the most difference.

Keep Breathing

There’s a stretch of the Pennsylvania Turnpike, between Lebanon and Reading, that I always seem to drive at night, when my family has fallen asleep in the car, and our road-trip playlist has returned to Ingrid Michaelson’s “Keep Breathing.”  You may know the song, with the spiraling crescendo at the end that goes, “All I can do is keep breathing,” a dozen or more times, as I hurtle through the darkness. If you don’t, click the link and let it play while you read the rest of this piece.

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Lifeworld Turned Upside Down

I haven’t written in ages. Even before the COVID-19 pandemic began there was always something getting in the way of the next installment of this blog. And all of a sudden, in the last 10 days, there is nothing.

I live in Allegheny County, one of the 7 Pennsylvania counties now under a stay-at-home order from Governor Wolf. I now have nothing but time. And what I am thinking about in this copious time that I have is how my views of healing must change in the face of calamity.

I have spent my career, 9 years of training and a dozen of practice, developing an art of medicine that is intensely personal, spiritual, and individualized. Touch, eye contact, and social intimacy with a person and their loved ones are the bedrock of how I care for people. At the moment, they are also toxic, the moral equivalent of a frontal lobotomy, or giving thalidomide to a pregnant woman. What kind of a doctor am I going to be now?

I have been quietly suspicious of the rise of telemedicine, fueling the demand for immediate gratification at the expense of building a lasting relationship with a trusted provider. Now my colleagues and I in primary care find ourselves dependent on it, racing to learn, and to teach our patients, how to use Zoom in a way that is secure, meaningful, and natural enough to actually have a real visit.

I have been slowly retraining my physical exam skills, with the help of Abraham Verghese and colleagues’ Stanford Medicine 25, learning the nuances of examining the tongue and honing my skills with an ophthalmoscope. Now, when doing direct ophthalmoscopy is tantamount to using coronavirus shaving cream, I will need to invent the skill of getting a patient with shoulder pain to perform a Hawkins and Neer test on themselves while I watch on my mobile phone.

I have been getting ever-more-proficient at observing body language in the exam room. Now I will be doing most of my visits looking at a disembodied head and shoulders that looks like it has been filtered through a funhouse mirror because no one in America knows how to make themselves look normal on a selfie camera.

So in this moment of Hamiltonian calamity, when the world has turned upside down, I am grateful to Adeline Goss, a senior neurology resident at UCSF, for her piece in last week’s JAMA. Goss is what we called a “non-trad” in my medical school years – someone who came to medical school after a “non-traditional” pre-medical career in the real world, in her case as a public radio reporter.

That career taught her rich lessons in how to listen to people’s stories, the kind of skills I value above all else in medicine. Yet as a doctor, Goss reached a point where she realized she was taking shortcuts on those skills, rushing people, directing their conversation instead of letting the conversation direct her, and assuming masks of interest instead of being interested.

Breaking out of those shortcuts has led her to develop new listening habits, which are already bearing fruit. I won’t spoil her story; you can click on the link above and let her tell it. But in this crisis, I realize I will need my own new habits, and fast. It would be all too easy to default into simple triage mode: sick enough to go to the hospital, not so sick but probably infected with COVID19 and needs to stay home and not speak to anyone, or chronically sick but needing elective procedures or visits with specialists that can’t happen in this climate so they’ll just have to wait.

I hope that, like Adeline Goss, I can find a different way, even under the incredible weight that I feel, to heal people. To learn to listen again – since I can’t easily rush them off to a specialist, draw lab tests, or inject their knees with steroids, really focusing on the clues in their story, the forgotten notes from past visits that help me form a pattern, the “non-medical” worries like a failing business or crushing loneliness that are the real reasons for the visit. I like to think that I am good at these things, but I know how I feel at least 30% of the time at the end of the visit – like I have done something just to feel like I did something.

The new setup gives me the chance to call people back as often as I want – my telehealth visits seem to be about 5-10 minutes shorter than before and as on time as I care to make them, with limited physical exam, no need to write orders before the person checks out or goes for labs, and no need to wait for the room to free up before we start or the patient to negotiate traffic. I can have more frequent, richer conversations with more people – and the visit with me can be a vital connection to another person instead of another chore in a long day.

There is only one story in the news today, and that is COVID19. It’s up to me, and people like me, to remember that the other stories, billions of them, that made up the Lifeworlds of all the people who have COVID19, who will yet get it, and who will never get it, have not ended. Those stories are still going on, and they just got a hell of a lot more complicated. I pray that, like God that hears prayer, I can spare both of my ears from the news to hear those stories.

If Jethro Ran Your Hospital

There’s an old saying that your stuff will expand to fill the space you have for it.  Live in an efficiency, and you will soon be longing for a two-bedroom.  Move into a five-bedroom home, and you will need to have a yard sale before too long.

Jobs are the same way, with medicine leading the way.  Squeezing in one more patient, adding one more documentation requirement, completing one more form, and yes, even spending five more minutes with a person than they are allotted, can easily add up to a 92-hour week.  It is a recipe for burnout.

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