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A Great, Bitter Cry

Everyone in Florin heard the scream.

In S. Morgenstern’s Classic Tale of True Love and High Adventure, known to most Americans as William Goldman’s The Princess Bride, the evil Prince Humperdinck tortures the hero, Westley, to an agonizing end.  At the moment of his passing, he lets forth a death scream that can be heard across the city and into the countryside.  No one knows what it is – except for one man.  Inigo Montoya, the Spanish master swordsman whose father was slain before his eyes when Inigo was only six.

“Inigo grabbed the giant and the words began pouring out: ‘Fezzik – Fezzik – that is the sound of Ultimate Suffering – I know that sound – that was the sound in my heart when Count Rugen slaughtered my father and I saw him fall – the man in black makes it now – “[1]

And the Egyptians made it then.  At the culmination of the plague of the first born, on the night that the Exodus began, “And Pharaoh arose in the night, with all his courtiers and all the Egyptians—because there was a loud cry in Egypt; for there was no house where there was not someone dead.”[2]

“A loud cry” – in Hebrew, tz’akah g’dolah.  The cry of Ultimate Suffering, as Inigo Montoya would call it, that one cries when one loses a parent, or a child, or – everything.

This is not the only place in the Tanakh where someone cries like that.  What’s remarkable about this is whose crying we are noticing.

The phrase wouldn’t have caught my attention at all if it weren’t for the fact that I’ve chanted a similar phrase on Purim a dozen times: z’akah g’dolah u’marah, a great bitter cry,[3] the cry Mordechai utters when he learns that Haman plans to destroy all the Jews in the Persian Empire.  That phrase is no surprise: in the foundational text of Judaism, finding out that Mordechai the Jew is capable of suffering great pain and evoking our sympathy is completely on-brand.

More surprising is Genesis 27:34Kishmo’a ‘Esav et divrei aviv vayitz’ak tz’akah g’dolah u’marah ‘ad me’od.  “And upon hearing the words of his father [that Ya’akov had already received the blessing meant for Esav], Esav cried a very great, bitter cry.”  The Torah shows us the raw emotions of Esav, the brother who we’ve already been told shall have no part in the inheritance that will become the Jewish people, and to whom later generations would equate the Romans and other enemies of the Jews – the Torah makes Esav at least as human as Ya’akov, and certainly capable of the same emotions.

At a minimum, then, the verse about the cry of the Egyptians is teaching us that, like Inigo Montoya, the cry of Ultimate Suffering is a cry we must recognize when others cry it, even when those others are unlike us, even when they are our bitter adversaries.  Inigo and the Man in Black had never met as friends; before he hears the cry in the woods, the last time Inigo had seen Westley was when they were swordfighting to the death atop the Cliffs of Insanity.  Yet his heart instantly breaks for his former rival’s distress.

But the Esav verse should have been enough to teach us this.  Why do we need two examples of such a cry from one of Israel’s rivals to make this point?  There must be another lesson.

Notice the word missing from the Exodus verse: marah, bitter.  Both Mordechai and Esav cry “a great, bitter cry.”  The Egyptians’ cry is great, but it is not bitter.  Why not?

Think about what happens next in the other stories.  Mordechai, once he has assured the safety of the people, leads a campaign of revenge against the forces within the empire who allied with Haman and still wanted to carry out his plan even after he was executed.  Esav, after he’s done crying, vows to lie in wait and then kill Jacob once their father is no longer living.  They are behaving in the manner of their crying – they are bitter.  Bitter people look for someone to blame, someone on whom they can inflict the pain they are feeling – the way Humperdinck took out his pain and anger on Westley (is this a column about Torah or about the Princess Bride?  And really, what’s the difference?).

Even our hero Inigo is out for revenge: “Hello!  My name is Inigo Montoya!  You killed my father!  Prepare to die!”  He’s so obsessed with it that when he finally gets the revenge, he tells Westley, “I have been in the revenge business so long, now that it’s over, I don’t know what to do with myself.”  Westley’s answer?  Piracy, of course.[4]

What do the Egyptians do?  Unlike their leader, they do not harden their hearts to the suffering of the Israelites.  When they are suffering under the weight of a plague of darkness so heavy they cannot move, they provide their Israelite neighbors with silver and gold as an act of subversion against Pharaoh.[5]  When the plague of the firstborn strikes, the Egyptians don’t choose bitterness – they choose repentance.  “The Egyptians urged the people on, impatient to have them leave the country, for they said, ‘We shall all be dead.’”[6]  Rabbi Adin Steinsaltz explains, “The Egyptians realized that they had been stricken because they forced the Israelites to stay in their land.”[7]  They could have turned on the Israelites, initiating a bloody war that would have ended, as they said, with all of them dead.  Instead, they said, “enough already.”

I had the Aliyah when that line of Torah was read this past weekend.  Staring down at Exodus 12:30 in the sefer Torah was like staring into the seething mouth of a volcano, knowing the pain that those Egyptian parents were going through that night.  Ellen Frankel, in The Five Books of Miriam, comments in the name of Mother Rachel, “With the final plague, all of Egypt feels what it’s like to be a slave girl, who has no control over her fate.  And with the death of every firstborn, every Egyptian family knows what it’s like to be crushed like dry grain between millstones.”[8]  Every Egyptian family, and almost every family of every nationality that I care for on a daily basis.  We are all staring into that same volcano.

No political pundit or military leader can tell a story that will make those feelings okay.  They will never be okay.  The only question is whether those feelings will lead to a bitterness that cries for revenge, or to the ability to tune in to another bereft parent’s cry of despair.  The cry is the same whether that parent is an Israeli Jew or a Palestinian Muslim, a Russian or a Ukrainian, an indigenous Guatemalan fleeing violence or a white person in rural Kentucky who has lost more than one child to overdose or suicide.  Choosing the second path is not easy.  Even the Egyptians quickly forget their compassion and fall right in line when Pharaoh changes his mind and decides to pursue the Israelites to the sea.[9]

But choosing that path, of compassion and not bitterness, is the whole reason the Israelites were freed in the first place: so they could be reminded ad nauseum, thirty-six times in the Torah, that we should remember what it was like to be strangers in Egypt and be kind to strangers among us.[10]  So that we could be told, “Do not hate an Egyptian.”[11]  Just before the miracle of the Sea of Reeds, Hashem says to the people, “As you saw the Egyptians today, you will never see them again.”[12]  This fearsome enemy you are seeing now will never appear that way to you again.  Our sages believed that as the Egyptians drowned in the sea, Hashem forbid the angels to sing a song of victory out of sorrow for the death of Hashem’s creatures.[13]  And one Haggadah illustration, from a 17th century Venetian edition (shared with me by my friend Dr. Murray Gordon), even shows the Israelites pulling floundering Egyptian charioteers out of the water after reaching the other shore safely.

Listen.  That is the sound of Ultimate Suffering.  I know that sound – and so do you.  Let go of your bitterness and reach out your hand.

[1] Goldman, William. The Princess Bride.  New York: Ballantine, 1973. p 251.

[2] Exodus 12:30

[3] Esther 4:1

[4] Not in Goldman’s novel, or apparently in Morgenstern’s original either.  But it is in a film adaptation one or two of you may have seen… or memorized.

[5] Etz Chaim Chumash, 387, comment attributed to R. Benno Jacob.

[6] Exodus 12:33

[7] Steinsaltz on Exodus 12:33

[8] Frankel, 107.

[9] Exodus 14:8-9

[10] Bava Metzia, 59b

[11] Deuteronomy 23:7

[12] Exodus 14:13

[13] Megillah 10b, quoted in the traditional Haggadah text

Renew Our Days

I grew up watching Happy Days on TV. In one episode, Arnold’s, the drive-in “greasy spoon” where the characters all hang out, burns to the ground. When the gang tours the wreckage after the fire, Fonzie (played by Henry Winkler to whom I am not related) tries his signature cool guy move of banging the jukebox to get it to start playing a song.

The charred front panel of the jukebox falls pitifully to the ground.

We are all trying to go home again. Back to our former state of health, back to our youth, back to the good old days – those Happy Days the show refers to, the “simpler time” of the 1950s that people living through the turbulent ‘seventies thought they were nostalgic for. Ironically, when my friend Jeff Finkelstein lost his father Norman last fall, part of his nostalgia was to display the books his father had written – including my favorite, a book called The Way Things Never Were, about how misplaced all that 1950s nostalgia really was.

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At Arms Length?

There’s a reason I’m not a surgeon.

Last month our handyman came by to definitively fix our shower doors. I’d been “fixing” them almost as long as we’ve had them: hanging them back on the track when they fell, reattaching the wheels when the screws came out, or reattaching the bottom bracket when it wiggled completely off, and the interior door swung loose.  They were installed crookedly on day one, owing partly to my entire house being crooked (old mine shafts and shifting Western Pennsylvania bedrock) and partly to shoddy workmanship. I could never buy us more than a couple of months of being able to use both doors before I had to tell everyone not to touch the interior door or else. I know how to think, not so much how to wield tools. I could see where the problem was coming from, but in the implementation, something always went wrong. I needed Mark to bail me out.

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The Torah of Treating People with Substance Use Disorders

Originally delivered as the D’var Torah at Congregation Beth Israel, Vancouver, BC, Canada, Shabbat Yitro, 5784 (February 3, 2024).  Event co-sponsored by JACS Vancouver (Jewish Addiction Community Services). Edited for clarity.

When I was a senior in high school, a band called The Black Crowes released their hit song, “She Talks to Angels.”  The song opens, “She never mentions the word ‘addiction’ in certain company.”

Even so, she must mention the word more often than the Torah does, which is never.  The “Torah” of working with people grappling with substance use must be extrapolated from other topics we encounter in the text, like laws relating to electricity or space travel.  Unlike those twentieth-century inventions, however, addiction has been around since the dawn of time – we just didn’t mention the word.

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Unprepared

Seemingly everyone in my circle has been reading, and rereading year after year, the excellent book by the late Rabbi Alan Lew, This Is Real, and You Are Totally Unprepared.  Not just unprepared for a speech or an exam, not just “appling” (Rabbi Lew’s chosen word for freezing in a moment of decision) over what to make for dinner when you forgot to shop, but unprepared for the pivotal, life-and-death, soul-searching, fate-in-the-balance moment of judgment and redemption that is the “awe-filled days” of Rosh Hashanah and Yom Kippur. 

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Lamenting the Scent

I’m currently attending the Conference on Medicine and Religion at Ohio State University in Columbus. This piece was written during a session entitled, “Attending to Suffering and Acknowledging the Limitations of Medicine through Lament,” presented by Drs. Alex Lion, Ben Snyder, and Mona Raed, Rabbi Bruce Pfeffer, and Chaplain Anastasia Holman, all of Indiana University School of Medicine and Indiana University Health System, Sunday, March 12, 2023.

Scent is transient.

We read a lament from our Muslim cousins where their Prophet, by his example, gave those who followd him permission to grieve, to cry, to express sorrow (Hadith on Grief: Death of the Prophet’s son, Ibrahim).

He came and kissed his departed son, and inhaled his scent.

And we thought of the scents we remembered

Through the neglected sense.

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Uncle!

Between Moshe’s initial failure to win over the Israelites to his leadership and the beginning of the Plagues, the Torah interrupts with – genealogy?  And an incomplete one at that, listing only the sons of Reuven and Shim’on, and three generations of Levi.  It seems to be setting up the yichus of Aharon and Moshe, because the verse immediately after the genealogic information reads, “The same Aharon and Moshe to whom Hashem said, ‘Take the children of Israel out of Egypt.’” 

Buried in the genealogy, however, is foreshadowing of several later stories that occur during the wilderness years, including Korach and Pinchas.  But the line that caught my attention concerns a figure whose big moment, according to the Gemara, is coming very soon: Nachshon. 

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Juvenal Delinquents

Andrew Silow-Carroll’s op-ed last week (‘Quiet quitting,’ the sudden trend in work, sounds sort of … Jewish? (Hear me out.)) took me back to my undergraduate days at Pitt.  There, in a course on satire, I discovered that the Roman satirist Juvenal felt much the same about Shabbat as Fox personality Tomi Lahren would eventually feel about “quiet quitting”: (insert ancient Roman expletive here) LAZY!

The idea that we should accommodate workers’ desire to not work 168 hours a week has always been the subject of ridicule for some, dating back at least to Pharaoh.  A “work ethic” was the excuse for whipping enslaved people in ancient Egypt, in ancient Rome, and in the not-so-ancient American South (and, lest we forget, only 60 or 70 years earlier, the American North).  And post-slavery, it was the basis for disparaging impoverished countries, disadvantaged people, the labor movement, and anyone who wanted to go home and hug their kids before bedtime.

What was organized labor fighting for?  Silow-Carroll quotes Samuel Gompers on this: “the earth and the fullness thereof,” meaning that the laborers wanted to enjoy the fruits of their labors themselves.  But let’s be concrete: they were fighting to not be trapped and burned alive in their sweatshops.  They were fighting to not have to send their eight-year-old children to work instead of to school.  They were fighting to work less than 100 hours per week in filthy conditions.

The fight succeeded for a lot of them; work in this country is far safer than it was 120 years ago.  Even with their success, though, there are still workers who face danger daily – and that was before the first months of the pandemic added a whole new hazard to jobs like the meat-packing industry, among others.

So where does my profession, medicine, come in?  I write regularly about the covenantal relationship between a person and their healers.  How can a person, in good conscience, “quietly quit” a relationship like that?

It’s true that the work we do is on a different plane, both for our patients and for us, than sewing shirtwaists, smelting aluminum, or cutting steaks.  Setting work-life boundaries in medicine is not the same as powering down your laptop in the advertising industry.  Our emergencies are literal matters of life and death; our crises are potentially life-altering much of the time.  The people we serve are not faceless customers states or even oceans away – they come face-to-face with us in very vulnerable ways.  We know their names and their intimate secrets – and they often know us well enough to bring us novelty socks and ask about our children.  Where do you set a boundary in these relationships?  Sure, it can be done, just like we do it with friends and family who overwhelm us – but there’s a cost to that boundary setting in all three cases. 

Today’s practice of medicine doesn’t happen in one-on-one relational units, either.  This is not a town physician making 50% of their visits by house call and the other 50% in a private office in their own house and getting paid in chickens.  Physicians, PAs, and nurse practitioners, kal va-chomer nurses, pharmacists, therapists and phlebotomists are employees.  Their relationship boundaries are not set by mutual agreement between healer and patient, but by their superiors and regulators.

One group of doctors always had this problem – medical residents.  Prior to the early 1980s, residents everywhere would routinely work well over 100 hours per week.  It was a time epitomized by the following joke:

“What’s so bad about being on call every other night?”

“It means you miss out on half the good cases.”

Yet it was also epitomized by the adage, “The longer you stay, the longer you stay.”  Do one extra good deed for a patient, and before you finish, another nurse will find you to do something else and you will never leave.

The residents in that era hated it – and loved it.  They complained about the long hours – and felt guilty about the hours they weren’t around the hospital.  They counted down to their days off – then came into the hospital on those days to check on the people they were worried about.  And when they graduated and became attending physicians, they both continued the behavior and perpetuated the culture for the next generation of residents.

People burned out.  They got divorced.  They alienated their kids.  And occasionally they inadvertently killed someone – or themselves, by accident or deliberately.  When a sleep-deprived resident in New York City made a fatal medication error that ended the life of a woman named Libby Zion, the world noticed.  New York State, at the recommendation of the Bell Commission, adopted resident work-hour limitations designed to protect patients from further mayhem inflicted by half-awake trainees, rules that became national in 2003.  My partner finished residency the day before those rules went into effect; she often averaged 110 hours a week on hospital months.  I began residency one year later and got called into the principal’s office the first time I exceeded the mandated 30-hour maximum shift.  I never surpassed 86 hours in a week and hit that mark only once.

A curious thing happened.  The sleep deprived errors stopped.  So did the sometimes-fatal car crashes of residents driving home after too little sleep on call.  Yet the patients were no safer – because new errors took their place.  Errors committed because the multiple handoffs of patient care to fresh reinforcements meant that no one was fully, solely responsible in a “I’m just stopping in on my day off to check on Mr. Smith” kind of way, for knowing that person.  Sign out, the process of handing off responsibility, happened with one hand on the elevator button and one eye on the clock.

Which scenario do patients prefer?  Why, both, of course.  They want same day appointments for themselves and expect to be able to refer their friends and relatives to start seeing me the following week, but don’t want me to hurry through their appointment or cut the discussion off after the sixth complex problem they raise.  My longest tenured patients worry about me looking thin and tired, encourage me to see more of my kids and want me to go on vacation – but they want only to see me for visits, and to reach me by phone in the middle of the night while I am overseas.  They want, as we used to say when my youngest child was a toddler, a thing and its opposite.  Very much like the residents in the old system wanted a life outside medicine, as long as they could still be omnipresent and unfailingly dedicated to their patients.

One doesn’t quietly quit in this kind of environment.  One who tries is subject to shame from their colleagues, guilt from their patients.  One who doesn’t try burns out like a meteor entering the atmosphere – or may literally die trying not to.

It wasn’t just the auto accidents and suicides.  Ten years ago a troubled man opened fire in the lobby of our university psychiatric hospital, killing one person and wounding six more before police killed him.  Today this story is a bead on a string of rage-fueled violent attacks on health professionals at the places where we try to do our healing.  Between the shootings and the hazards of healthcare work in a pandemic, all the banging on pots and pans and Italian opera in the world isn’t enough to keep many professionals on the job.  A billboard I passed on my way to work last month carried the alarming statistic that 93% of hospital workers had considered quitting their jobs this year.  That’s not quiet quitting, that’s rock concert loud.  That is the Krakatoa of quitting.

It seems Pharaoh has finally taken away too many bricks, blown off too many plagues, and now it is time for the mass Exodus.  Our profession no longer cares if the likes of Juvenal thinks we’re delinquents; we want some balance in our lives while we still have lives to live.  But at what cost to the people we care for?

With every departure, the burden of care on those who remain – nurses, techs, providers – only grows, leaving less time for each person they care for, less attention to each detail, more chance of something being missed, or delayed, or ignored. The hazards only grow for those who remain. A pre-pandemic New York Times op-ed by Danielle Ofri pointed out that absent the altruism and self-sacrifice of doctors and nurses, the whole healthcare system would collapse.

It’s been thirty years since I took that satire class.  And this fall I find myself back on a campus I cannot seem to leave no matter how hard I try (I have even outlasted the O!) attacking this exact issue, and dozens of others like it, with 30-some undergraduate students in a class called “Healing and Humanity.”  Many of them poised to enter the health professions in just a few years, these students are interested in knowing more than just the workings of a neuron or the intricacies of the Starling curve (the math behind how our hearts keep contracting efficiently), but in how all of these things apply to the lives of whole human beings.  The same dilemmas I address in this blog, and in my book, will be the topics we grapple with in class.  How should we communicate with each other?  What should physicians wear to work?  What kind of rules should we have about showing up late to appointments?  And yes, where should healers set their time and space boundaries around work?

I’ll let you know what they think as the semester goes on.  Meanwhile, as we approach a month in which I’ll be missing about ten work days out of 30 to observe our holidays and take care of some business out of town, I have this thought:

Juvenal thought the Jews lazy for having a day off out of every seven, a practice that is now pretty much universal through the world (to quote my friend, Rabbi Danny Schiff, “You like your weekend?  You have the Jews to thank for it.”).  But two thousand years ago, in saving the life of a half-frozen scholar who would one day be known to all as the great Hillel the Elder, the pair of Shemaiah and Avtalyon concluded that saving his life, or any life, was more important than Shabbat.  In the twenty-three years that I have been attending synagogue while medical, I have hidden in the coatroom to take call hundreds of times, diagnosed appendicitis, fractured forearms, and positional vertigo, and called multiple ambulances.

It would be more than possible for me to never actually have a Shabbat, to never fully partake in the miracle of rest that Hashem gifted to us.  There is always a person in distress for whom I could construe myself to be responsible.  There is always someone who could construe me as the one person they need to help them.  If I gave primacy to every single one of these I would never rest.  It is because of people like me that Hashem gave Shabbat not as a “Look what I brought you!” but as a “Thou shalt.”  Because if it were left up to me, I would defer Shabbat until the next person to collapse in shul is me.  There isn’t just one Hillel, frozen up on the roof – there are hundreds, thousands even, and I know all of them too well to pretend it isn’t my responsibility to unfreeze them.

There is a prohibition in the Torah – that we read this very week – against encroaching on your neighbor’s boundaries. It’s such a strong prohibition that the entire nation curses anyone who dare’s move that boundary marker.  Maybe that’s applicable here – but first we need to figure out where the boundary is. Where can we draw the line between dedication and self-destruction, between altruism and self-abnegation?

Good thing I have so many eager students to help me figure that out.  Hail to Pitt!

Originally posted at https://blogs.timesofisrael.com/juvenal-delinquents/ ; this version has been slightly edited.

Copyright © 2022 Jonathan Weinkle. All rights reserved.