Purple Hats

Purple Hats

It’s easy to think that the entire profession of medicine is doomed to failure.  In my last post I talked about my family’s Rule Number One: Don’t Die.  But everyone violates Rule Number One exactly once in the end (unless they get CPR – then it might be twice, or even three times).  If the whole goal is to keep people from breaking Rule Number One, then, in the final analysis, we have a 100% failure rate.  To quote Kohelet, the book from which we will read during this week’s Sukkot holiday, “Utter futility, all is futile.”

The pandemic hadn’t even hit yet when I began to feel this futility acutely.  From April 2019 through the first whispers of a global shutdown I had lost about half a dozen long-time patients, some of them kept alive literally for decades through the heroic efforts of my most respected colleagues.  The COVID-19 pandemic merely accelerated the process.  In the past two years I have lost patients to COVID and chronic respiratory failure, colon cancer and coronary disease. 

Many of my guiding lights have also died during that time.  Rabbi Dr. Abraham Twerski, whose work in addiction medicine I read even before I chose this career, died in late January 2021.  Less than three weeks later, another mentor-from-afar, the cardiologist Bernard Lown, whose book The Lost Art of Healing influenced my practice of medicine more than any other I have read, died just shy of 100 years old.  And predeceasing them both by a few months, Lord Rabbi Jonathan Sacks, late Chief Rabbi of the United Kingdom.

I had just begun a year-long study of Rabbi Sacks’ series, Covenant and Conversation, his compilation of years of essays on the weekly Torah portion, about a month prior to his passing in early November 2020.  This week I reached the end of the line, completing the four essays on the final portion, V’zot Ha-b’racha, which tells the fate of each of the tribes and describes the death of Moshe.

Reading these essays, in which Rabbi Sacks grapples with the poignant tragedy of Moshe’s death, the end-without-an-ending that cuts him off in the middle of the story without a “happily ever after,” was like experiencing all of these losses again.  The loss of Rabbi Sacks’ wisdom, the loss of the professional compass of Dr. Twerski and Dr. Lown, and the loss of the people I had grown to love as I cared for them.

Yet these final essays also contained the balm for that sense of loss.  On the very last page of the book, in the essay titled “End Without an Ending,” Rabbi Sacks writes, “Life is not robbed of meaning because one day it will end.”  He is the anti-Kohelet.  Medicine is not a failure because it does not abolish death; it is a success because it enables life. 

Sacks’ essay, “Mortality,” the penultimate one in the book, reminds us that death is a necessary condition for the urgency that makes us live our lives with purpose.  The Torah, he says, is bookended by death: the loss of immortality by Adam and Eve in the Garden of Eden at the beginning, and Moshe’s death at the end.  “In both cases we are conscious of the beyond: the beyond of Eden, paradise lost, and the beyond of the Promised Land, paradise not yet gained.  These two define the human condition for us as individuals, and for homo sapiens as a species.  We live in the between, the liminal space between two eternities, the world of harmony that once was and the age of harmony that will be but is not yet.”

In that light, my job as a physician is not to vanquish that which cannot be conquered, but to allow a person to hold that liminal space as long, and as well, as they can.  I called my book Healing People, Not Patients because I wanted to restore focus to the human being, created in God’s image, and not to the minute technical details of physiology.  Nowhere does that distinction matter more than here, confronting death and trying to stave it off just a little longer. 

It means everything in the world that I am not simply adjusting dials and titrating medications to maintain a pulse, keep someone “breathing over the vent,” or sustain occasional blips of brain wave.  Rather, the work that I do as someone is failing, as we consider the possibility that this might be their last Thanksgiving, their final summer, my last visit with them, is meant to keep alive a person who still has more purple hats to knit.  It is intended to allow a person to hold on until they have said goodbye and happy birthday to a beloved child.  It is designed to allow a dying man to finish mourning for his recently deceased partner.

Rabbi Sacks strikes a rare balance between fighting death, even quoting Dylan Thomas’ famous “Do Not Go Gentle Into That Good Night,” in support of Moshe’s refusal to accept his decree, and accepting death as described above.  Of course we should fight; the world needs more purple hats.  The world needs more elderly fathers with hands folded over the handle of their canes, nodding sagely at their doctors.  The world needs people to rejoice, even just for a few days, over finally becoming Americans – or over discovering that, in fact, they had been citizens all along and never known.  We need not win the fight forever.  We just need to win today.

“Winning” has different definitions to each of these people and their families.  While the miracle of modern medicine often gauges its success on “outcomes,” people do not use such monolithic endpoints.  We use purple hats, hugs, witty remarks and wise words.  In an essay on Parashat Ha’azinu entitled, “Let My Teaching Drop as Rain,” Rabbi Sacks explains that the title line means that the teachings of Torah enable human beings to each grow into the unique individuals they were meant to be, the way rain enables each plant to grow and produce fruit the way it is meant to do. 

I like to think of my medicine this way, as sustaining life to enable the moments, the outcomes, the endpoints that have meaning for the people experiencing them, even if they don’t show up in the “metrics.”  If my goal is ending the pandemic with a metric of Zero COVID, then Kohelet was right, as right as he would be if I wanted to reach Zero Cancer, or Zero Death.  But if my goal is to enable one more family reunion, one more citizenship ceremony, one more purple hat – or one more meal in a sukkah – then let it fall like rain.

But don’t let the rain fall in my sukkah.  There will be time for that later.

Please remember that you, too, can help people knit their purple hats, or whatever makes their lives meaningful. Consider a donation to Hebrew Free Loan of Pittsburgh, www.hflapgh.org.

Photo by the author; hat by Jodie Black. This post is written in her memory, with permission of her family.

The Bedford Award and Hebrew Free Loan

The Bedford Award and Hebrew Free Loan

I’m honored to share that on October 7, 2021, I will be awarded the Nathaniel Bedford Primary Care Physician Award for 2020 by the Allegheny County Medical Society. Dr. Bedford was the first practicing physician in Pittsburgh, and namesake of Bedford Ave. in the Hill District (as well as the person who decided to name Carson Street after a friend who was a ship’s captain). You can read all about the award here. The award comes with $1000 to be donated to the charity of my choice, which I have chosen to give to Hebrew Free Loan Association of Pittsburgh.

Hebrew Free Loan provides interest-free loans for large, one-time expenses that can make the difference between a family forging ahead or falling to pieces. Purchasing a car, adopting a child, releasing a new album of music, or finishing graduate school are only a few of the things that this vital organization has helped provide for. One of the keys to primary care medicine for me is recognizing the role that a person’s lifeworld plays in their well-being, and the needs that HFLA-Pittsburgh helps to address are among the most important parts of that lifeworld – career, transportation, starting a family or pursuing a dream – and I have regularly referred people to them because I knew that their assistance might mean more to that person than any medicine I could prescribe.

My wife Vita Nemirovsky, a former HFLA board member with whom I am co-chair of HFLA’s fall fundraising campaign, likes to say that HFLA “recycles money.” Since these are loans, repaid typically over 2-3 years, one donation ends up helping a series of people over decades, with very little overhead. Not only that, but the loan continues to help the borrower even after it is repaid by serving as a way for someone who might not qualify for conventional loans to build their credit and make it easier for them to hold a credit card, rent an apartment, or purchase a vehicle on their own in the future.

I’ve already received a lot of well-wishes for the Bedford award, but what would really make me happy is if everyone reading this would consider a donation to HFLA Pittsburgh. Healing People, Not Patients doesn’t happen in isolation, and by doing so you would be directly contributing to the work I do, even if you can’t stand the sight of bodily fluids and don’t remember which side the liver is on.

“And You Shall Surely Heal…”

“And You Shall Surely Heal…”

If I had a hero in my life, it was Bernard Lown.  I was one year into my medical education when I “met” him, by way of discovering his book, The Lost Art of Healing, in a Half-Price Books on McKnight Road on my way to Montreal in the year of the millenium.  That chance meeting was the real beginning of my medical career, whatever other stories I might tell to the contrary.

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Golden Guilt

Golden Guilt

Fill in the blank in this popular saying:

“Silence is _________.”

I would wager that if you are of my parents’ generation, an early Boomer or older, you answered “golden.”  The adage conjures images of whispering in libraries and children being seen, but not heard.  My children’s generation and the one immediately preceding it, the millennial and post-millennial cohorts, answered “assent.”  They disdain silence, because it is the posture of those who sit on the sidelines while racism, sexual assault, environmental destruction and economic exploitation proceed unchecked.  One generation’s gold is another’s guilt.

I am in my late forties, a Gen-Xer stuck in the sandwich between these two generations, paralyzed into involuntary silence by not knowing what to say, how to say it or whether anyone wants to hear what I have to say to begin with.  I feel golden and guilty all at once.

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Giving Voice to the Speechless

Giving Voice to the Speechless

It’s been a long year. For the last couple months I’ve fallen silent, no small feat for me. Nothing I had to say seemed equal to the task of the chaos around me.

I think I’ve found my tongue again. The Nishmat prayer that paves the way into the main section of Shabbat morning services refers to Hashem as mekitz nirdamim, mesiah ilemim – the One who wakes the dreamers and gives voice to the speechless. I’m feeling more awake than I have in a long time, and plan to be sharing a lot more material over the coming months here on this website and over my social media channels, where most of you will probably be reading this, starting with my newest installment of my Times of Israel blog, which is actually about mekitz nirdamim, waking the dreamers. That should post by tomorrow.

I haven’t been completely idle; aside from my day job I’ve actually had a few speaking engagements lately. Check out the Events page to see what I’ve been up to despite the pandemic, and “where” I’ll be next. There are at least two talks coming up in February and March, and I’m always open to discussing new virtual events (and eventually in-person ones) if you’re interested. Tag me on one of the social media platforms and we’ll talk, or email media@healerswholisten.com.

Where did this return of energy come from? Who knows. Maybe Hashem decided to give me a reprieve – or maybe it was the new puppy.