The Same Joy

The Same Joy

Remarks from a “FEDTalk” given at the annual meeting of the Jewish Federation of Greater Pittsburgh, September 5, 2019.

It was the morning of March 17th.  48 hours earlier, a co-worker had alerted me to the horrible terror attack in Christchurch, New Zealand.  I had been in a fog ever since.  The young Syrian man across from me stared at the floor and told me, “I watched the video online – he wasn’t showing any emotion.  He was shooting people like it was a video game.”

Less than five months out from our own communal tragedy, I thought I had begun to heal myself.  Christchurch ripped open the wounds – his memories of the catastrophic disintegration of his home country into civil war, and mine of the loss of dear friends, colleagues, and co-workers, and of my illusion of being secure in our wonderful Jewish community. 

It was a conversation particular to the Squirrel Hill Health Center.  While we are not a “Jewish health center,” SHHC grew out of the Jewish Healthcare Foundation, is a Federation beneficiary, and in many ways is a living legacy to Montefiore Hospital’s tradition of serving all of the underserved communities of Pittsburgh.  Those underserved include refugees and immigrants whose language, culture or religion serves as a barrier to care in many places.  SHHC was also where our late, beloved friend Richard Gottfried worked until the day before he was killed while davening with his community at New Light. 

I suppose I’ve known for years that a conversation like this would happen one day.  Last fall, just a month before the 18th of Cheshvan upended all our worlds, I reached a major career milestone.  My book, Healing People, Not Patients, was finally published thanks to generous support from the Jewish Healthcare Foundation.  The premise of the book is simple: people who heal for a living are in a relationship or, as Rabbi Harold Schulweis suggested, a covenant with people seeking healing.  Thinking of those seekers first and foremost as people, created in God’s image, demands a completely different approach to healthcare than our current model that often reduces a person’s identity to their diagnosis or even their room number.

The most crucial skill in this covenant is the ability to listen attentively to another person’s story, and to ask them questions out of genuine interest in knowing more.  My friend Martin often admonishes me not to ask questions I don’t want to know the answer to.  Well, in the aftermath of a tragedy, I don’t want to know the answers.  I’m not sure I can handle the answers anymore.  Yet those answers are the key to helping the other person heal.  What was I supposed to do?

My young Syrian friend is not the only person I care for to have experienced trauma.  “Trauma-informed care” is one of the newest buzz-words in healthcare, and especially in mental health.  But Dr. Megan Gerber, author of the first textbook on trauma-informed care for primary care docs like me, distills this buzzword into a stark realization: depending on where you are, a history of trauma can be nearly ubiquitous.  Consider the SHHC team to be fully informed.

What isn’t ubiquitous is what grows out of that history.  Gerber makes the point that people who have been traumatized may be angry and frightened, jumping at a touch or snapping at every perceived verbal micro-aggression, even when the intent of that touch is to soothe or that speech is to counsel.  Others bury the trauma almost as soon as it occurs. 

Trauma can lead to chronic pain and disability: a back bent into the shape of the lowercase letter “r” which bows even further on the yahrzeit of a lover.  At the other end of the spectrum, health workers whose patient dies in mid-shift return to work within minutes.  I debriefed after my first experience of a patient’s death in the stairwell of the VA hospital only because the intern supervising me took two minutes to stop and check on me as we ran past each other in opposite directions. 

Jewish tradition prescribes a middle path.  We find triumph in tragedy, and remember tragedy in moments of triumph.  The chevra kadisha, of which our community is blessed to have two that work in cooperation and respect, does a tahara using texts comparing the deceased to a bride, or to the Kohen Gadol.  The mashiach is going to be born on Tisha B’Av.  The broken glass at a wedding tempers our joy with a memory of Tisha B’Av.  And at one point in history, that wedding was likely arranged on the afternoon of Yom Kippur, when the life of each Jewish soul is hanging in the balance. 

Saturday, November 3, 2018, the 25th of Cheshvan, when 1500 people crowded the sanctuary at Beth Shalom to mourn and daven together, we ended Kiddush by celebrating the sheva brachot of our Rabbi, Jeremy Markiz, and his wife Elana Neschkes.  They married on the 19th of Cheshvan in Los Angeles, and bound by the mitzvoth to rejoice that entire week, even in the wake of unspeakable tragedy.  If it is possible to be both broken and restored in the same moment it happened to me as I struggled to sing for the bride, “Kol sasson v’kol simcha, kol chatan v’kol kalah.”

Remember that stark realization about the ubiquity of trauma?  Megan Gerber reminds us healers of an even more stark truth: many if not most of us have also been traumatized.  We not only need to be broken and restored in the same moment – we need to be broken and restore others in the same moment.  Gerber might well paraphrase my friend Martin and say, “Don’t asked questions if you’re not fully prepared to deal with the answers you get.”  But we had to be prepared; we had to continue. 

The weeks and months that followed the shooting were a pendulum swinging between attending to the pain and suffering of those we had always cared for, and tending to our own wounds.  There was Rich’s funeral, the cookie trays and lunches, the Bhutanese community vigil, the outreach from JFCS.  Despite their own vulnerabilities, their limited English, their own emotional exhaustion, the seekers were now healing the healers.  Their example inspired what I am going to share with you now.

Fans of medical Latin may have heard the term furor therapeuticus, a term the great teachers of medicine often apply to their students who simply cannot stand to leave a problem un-fixed, often to the great detriment of the person with that problem.  The golden age of medicine that dawned in the sixties and continues to this day filled many of us with the belief that every disease could be cured, every hurt healed, and even death made optional.  We learned to say, “No one needs to be in pain.”

As we become trauma-informed we are learning to say, like Rosey Grier, “It’s all right to cry.”  Healers like me who have never really learned properly to shut up now recognize that it’s also all right not to have an answer to the crying.  We just need to name it, and be present with it, and share the tears. 

Pittsburgh Jews are now trauma-informed whether we like it or not, aware of both the ubiquity of trauma experienced by others, and of our own inability to escape trauma ourselves.  It seems preposterous that after 2,000 years we should need to be reminded of the ubiquity of trauma, but individual memory is short. It’s hard for one person to remember what it’s like to be a “stranger” when we are no longer feeling so “strange.” Now, our own immediate experience parallels that of those we support, and of those we try to heal.

Erica Brown, who came to comfort our community on the shloshim, and who will return here later this month for the Fall Forum, takes exception to the five-stage Elisabeth Kubler-Ross paradigm of grief.  In her book Happier Endings, Brown contends that there are really only three stages: denial and resignation, which encompass all five of Kubler-Ross’s original stages, and inspiration, in which a new life is formed, absent that which was lost, yet incorporating it into something greater which did not exist before the loss.

The inspiration stage is digging into that parallel experience to help others.  Before the shooting I would sometimes ask myself, “What can I learn from my patients who have survived war trauma and are thriving that could help others who are not?”  Now I am looking at myself, asking how we might help each other. 

Answers are already emerging: by returning support to our Muslim neighbors who rushed to our aid in October.  By sending letters to the survivors of the more recent tragedies in Poway, Dayton, Gilroy, El Pason, and now Odessa-Midland.  By tapping the resource of our Holocaust survivor community to support our Hillel JUC students, or to partner with SHHC to help Bhutanese refugees process their own tragic losses.

This is variation of the phenomenon known as “concordance:” people build more trust and experience greater healing with a healer who is similar to them in gender or ethnicity.  In the Talmud, Nedarim 39b, Rav Aha bar Hanina speaks of a different kind of concordance, necessary for effective healing when visiting a sick person – to be “ben gilo.”  One translation is that this means to be of the same astrological sign, but as always, there are other ways to read this. 

Gil – age.  One of the same age may be more of a comfort that someone too young or old. 

Gil – joy.  One of the same temperament, who enjoys same things, can provide greater comfort than someone with whom we have nothing in common. 

Gill’galot, to reveal.  If we are vulnerable, broken, and willing to share that vulnerability with the others, we connect in a way that armored stoicism and charmed innocence do not allow. 

Glu’im – exposed.  The media encampment last fall left us exposed, but in that exposed vulnerability is our strength, our newfound ability to be there for each other. 

L’galot – to discover, strength we did not know we had. 

Gilinu, we discovered this year what we already knew.

We are surrounded by bnei gileinu, our friends and neighbors with whom we have a special, Pittsburgh concordance. 

Bo’u ngaleh, let us show the rest of the city and the world what we have to share with them.

Facial Recognition

I catch a half-smile, a hesitant wave, and a curt nod, and I realize I am supposed to recognize this person.  I return the gestures, but my memory refuses to be jogged.  Finally, they approach me close enough for conversation, and say, “Dr. Weinkle, how are you?”  After caring for a few thousand people in the course of my career, I cannot hold all the names and faces in my head any longer.  “I’m so sorry,” I reply, “please remind me of your name.”

The double-edged sword of “recognizing faces”
From https://thepioneeronline.com/category/metro/

If only I had chosen to be a judge.  According to the Torah, they’re not supposed to recognize faces – it says so right in Deuteronomy 16:19, when Moses is explaining the meaning of “judge the people with righteous judgment.”  Among other things, he says, “thou shalt not respect persons,” meaning not to show favor to a rich person because of their status, or to a poor person out of pity.  Equal treatment under the law is the meaning of righteous judgment.  But the Hebrew phrase that he uses to say this is lo takir panim – literally, “don’t recognize faces.”

But healers aren’t supposed to be blind like justice, are we?  We’re not meant to be impartial – we are meant to be completely partisan advocates for our own patients.  Haven’t I written a whole book, and dozens of blog entries, about how I want my colleagues to feel a certain amount of love for the people we care for, to really care instead of just “providing care?”

Knowing the face, being familiar with the person, is the essence of individualized, person-centered care.  You can’t be a “healer who listens” without understanding the uniqueness, “recognizing the face,” of the person you’re listening to.  By extension, you can’t know which person needs hand-holding and which one humor, which one deliberation and which one decisiveness, unless you know their “face,” the way they prefer to interact with the world.

But when you have a busy practice, how many faces can you “know?”  Can I be fully present for every single one of them, know all their preferences and tailor all my treatments to their needs?  Does every one of them get my equal passion?  Or are there a few faces that inevitably end up getting more attention?

Put another way, like that encounter on the street, there may be a limit to the faces I can recognize at one time.  So which faces am I going to end up seeing?

Over 11 years of my career I’ve seen myself default in a whole variety of directions.  Sometimes I “see the faces” of the people who happen to be in the office that day, to the detriment of those calling in from home.  Other days I dive into the first appointment of the day with 1000% commitment, only be insurmountably behind schedule by 4 pm, unable to see the faces of the last two or three people on the day’s schedule.  Still others, I am so consumed by the faces whom I can’t get out of my head at night, from the constant worry about their well-being, that the simple needs of the faces who just need a moment of my time are never seen.  And yes, sometimes I recognize the faces of the squeaky wheels and spend my time putting grease on them while the patient patients continue to languish.

My children might tell you that this arrangement is OK, because they’ve often heard me tell them, “Fair doesn’t mean equal.”  Not everybody gets the same amount of something, and that can be OK – but only if everyone gets the appropriate amount for them. 

“Recognizing faces” can have consequences beyond just how we allot our time, though.  Recognizing certain faces, and failing to recognize others, directly impacts the care that we provide.  We’ve all seen a child in pain; most of us who have our own children can even tell when they are really in pain and when they are simply shocked and betrayed that one of their siblings has whacked them with the broom.  Yet somehow when black children come into the emergency room with appendicitis, we find their pain harder to recognize than that of white children.[i]

Recognition often becomes easier when the face is one that looks like our own, a phenomenon called concordance.  There’s evidence that concordance can significantly improve care, reducing alcohol consumption in the aftermath of a traumatic injury, or leading to more rapid follow up of abnormal cancer screenings in populations where the patients and physicians are from the same background, where looking in the healers face feels a little more like looking in the mirror.[ii]  Recognizing faces can save lives, too.

Still other times the recognition can go too far.  We may be loath to admit it, but all of us have at some point cared for a person who was a “VIP patient,” whether a close friend, a famous person, or someone with an “in” at our place of employment that made them feel entitled to more expensive, more rapid, or more cutting-edge care than the other patients.  If we’re going to talk about recognition, let’s recognize what’s going on when we do a test we know doesn’t need to be ordered, acquiesce to a demand for an antibiotic or an opioid that isn’t called for, or change our practice that we do the same way, every time, “just this once” because we give too much recognition to one particular face. 

Orchot Tzadikim (a text from the musar, or ethical, tradition of Judaism) relates how learned people can shame the very holy texts they are studying when they do not act accordingly.  The example given is of when one studies the line, “You shall not be prejudiced in favor of the mighty,” but then does show favor to a wealthy person in court.  When we study the evidence and learn best practices, then toss them out the window when caring for a VIP patient, we bring shame on medicine as well.

There’s no easy way out of this conundrum.  When I wrote in Healing People, Not Patients about creating my worry list, I wondered how I could ethically, fairly decide who I was sufficiently worried about to put them on the list.  I initially wrote that chapter three years ago; I’m still struggling with the question.  How do you create the oxymoron of “universally individualized care?”  How do you do the “right thing, for the right patient, at the right time, in the right way,” to quote the patient safety mantra, without inevitably having your individual relationship with the patient push someone else out of the way, or cause you to behave differently for that patient than you would?

While you think that over, I’m going to go grease some squeaky wheels.


[i] Goyal, MK et al. Racial Disparities in Pain Management of Children With

Appendicitis in Emergency Departments. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.1915

Published online September 14, 2015.

[ii] Poma, PA.  Race/Ethnicity Concordance Between Patients and Physicians.  Journal of the National Medical Association, 2017-03-01, Volume 109, Issue 1, Pages 6-8.  Poma cites numerous other studies in his review; the two referenced here are by Field and Caetano and by Charlot, Santana, Chen et al.

Surviving Sinai:

Surviving Sinai:

Modern day Exodus stories, and what happens when they are “over”

I speak in metaphor a lot. One of my favorite ones is using the Exodus from Egypt as a metaphor for healing from illness. The idea is that illness is a narrow place which does not permit a person to be truly free. Only by way of a long, difficult journey does a person leave the land of illness and its constraints and arrive in a new, hoped for place of wellness and plenty.

Two weeks ago I had to code switch. I met several people who had literally left Egypt and relived the journey of the ancient Israelites, looking for a place that was wide enough to allow them to breathe freely. Lest you think I’m putting my own gloss on someone else’s story, I mean to say that these individuals crossed through the Sinai desert. They made the crossing on foot and under attack from all sides, from a modern day Amalek of torturers, rapists and extortionists.  Their destination was the modern Israel.

One of them, a young Darfuri man named Usumain, took the analogy a step further.  He recalled being in Egypt, having already rejected Libya and Chad as suitable places to remain after fleeing for his life from the conflict in Darfur.  One night he was watching television and saw a program on Al Jazeera that told of the history of the Jews, including the Exodus from Egypt, and up through the genocide of the Holocaust.

“That’s me,” Usumain said to himself.  “I am running from genocide, and I am in Egypt.  But there’s no way I can wait forty years, I must go to Israel now.”

That was eleven years ago, when he was fourteen years old.  I met a 25-year-old Usumain in Tel Aviv this month, strolled with him through the streets and had lunch with him.  During those couple of hours, one thing became clear: there is a mirror image to my metaphor.

I’ve been relying on the Exodus metaphor as a road map to healing since the day my mentor, Rabbi Larry Heimer, introduced me to the idea.  Rabbi Yitz Greenberg’s chapter, “Judaism as an Exodus Religion,” is one of the founding documents of my personal philosophy of medicine.  This encounter with Usumain turned that concept on its head – the Exodus from Egypt can also be an experience from which one needs to heal.

Ancient or modern, a person who embarks on that journey faces thirst, starvation (see Numbers 20 for just one of the numerous Biblical examples of both), dangerous enemies (Numbers 22:2 and onward for the story of Balak, King of Moab, and the sorcerer Bil’am who was sent to curse the Israelites, or the stories of Og of Bashan, Sihon of Emor, and the people of Amalek attacking the weakened stragglers in the Israelite caravan) and despair.  Families separate; Usumain’s mother and sisters remained in Chad, while his brother sought asylum in the US.  Among the ancients, some Israelites preferred the known devil of slavery in Egypt to the unknown of a God taking them out into the wilderness.  Some die in the wilderness – Miriam, Aaron, Moses, the entire generation of adults who came out of slavery, and in Usumain’s group of 12 refugees alone, 3 fellow travelers shot dead by the Egyptian army trying to cross into Israel.

Arriving in the “Promised Land” does not bring the journey to a close.  One doesn’t just get to drop anchor beneath a vine and fig tree and live in peace and unafraid, as the prophet said.  One arrives at a destination where they don’t speak the language, where they are unwelcome, and where poverty and starvation are still a potential outcome.  Another Exodus, to another possible promised land, may be just around the corner.  Ironically, I met Usumain in South Tel Aviv, near a neighborhood called Neve Sha’anan, “the tranquil dwelling place.”  I couldn’t help but think instead that for Usumain, the commonly used Hebrew phrase, “ein sha’ananim b’Tzion” – there is no tranquility in Zion – is more applicable.

Tranquility is hard to come by elsewhere in the world as well.  Metaphorical Sinai crossings in other parts of the world also end in sexual assault, death from asphyxia and heatstroke in a truck-turned-oven in the Sonoran desert, or in a cage in the supposed “land of the free.”  Usumain chose Israel as his destination in part because he didn’t want to end up drowning on a raft in the Mediterranean, like so many African refugees before and after him.

Cynics in wealthy countries from Central Europe to the US have suggested that the migrants should have sought asylum in the first country they came to, as if this would somehow solve the problem (perhaps it would – it would save the wealthy nations from having to acknowledge how fortunate we are).  A laughable notion: should Sudanese refugees seek asylum in Chad, one of the two or three poorest nations on Earth?  Should the Congolese refugees that left in 1994 expect a homecoming in Rwanda, a country that had literally months before been torn apart by a genocide?  Refugees fleeing Somalia in the 1990s and 2000s ended up in refugee camps in Yemen – I wonder how their asylum cases would be going right about now? 

Usumain’s story ends well; he is one of a very few to gain official refugee status from among the Sinai survivors.  Thousands of others are still in limbo.  But even when the political drama reaches a conclusion, there is an internal drama of nightmares, anxiety, depression and flashbacks that continues.  It is not unique to the Sinai refugees, be they men from Darfur or women from Eritrea, but it is a further reminder that an exodus is both a journey to healing and a journey from which one must heal.

I left lunch with Usumain and soon found myself having coffee with Aeden, one of the Eritrean women I just mentioned, at the Kuchinate Gallery[i] a short distance from Neve Sha’anan.  Kuchinate is the Tagrinya word for “crocheting,” and that is what happens at the gallery.  Women like Aeden support themselves and their children by producing baskets in a traditional style, which the gallery buys from them no-strings-attached and sells to keep the doors open, the lights on, and food on the table for the kids in the afternoons. 

But Kuchinate, I learned, is about more than livelihood.  It is its own form of healing.  In a culture where unloading your troubles on a stranger with an impassive face is a laughable idea, the gallery brings together women who become fast friends and can confide in each other about the horrors they have experienced.  Both the work, and the comraderie that it creates, are their own form of therapy that may be more relevant than all the CBT in the world.  Among the Nepali-speaking refugees I care for, there has long been an idea that “a friend is a psychologist;”[ii] Kuchinate allowed me to watch this saying in action in another culture from another continent.

There’s also a lot of self-healing going on at Kuchinate.  The gallery’s director, Dr. Diddy Mymin Kahn, joined with an Eritrean nun that everyone calls Sister Aziza to produce a book, A Guide to Recovery for Survivors of Torture,[iii] written in English and Tigrinya with culturally relevant drawings and blank pages for notes, that walks a survivor through the process of healing moment-by-moment, helping them to feel safe, conquer basic fears like agoraphobia, and combat anger, depression and despair.

There are 60 million people in the world today estimated to be in the midst of writing their own Exodus narrative.  It is a public health crisis on the same order of magnitude as HIV/AIDS, malaria or tuberculosis.  Both the social services and the mental health services in almost every one of the “promised lands” these Sinai-crossers are striving toward, not to mention the places many of them languish in the meantime, are underfunded and overwhelmed.  It will be because of individual resilience, and because of the embrace of intimate friends like Kuchinate, that they will someday be able to complete their journeys and recover from their travels.  Day to day, I strive to provide that embrace in my work.  I invite you to join me.


[i] https://www.kuchinate.com/

[ii] Liana Chase and Ram P. Sapkota.  ‘‘In our community, a friend is a psychologist’’: An ethnographic study of informal care in two Bhutanese refugee communities.  Transcultural Psychiatry 2017, Vol. 54(3) 400–422.

[iii] Dr. Diddy Mymin Kahn and Sr. Azezet Habtezghi Kidane, tr. Mebrhatu Baraki and Kebedom Mengistu, ill. Karen Brockman.  A Guide to Recovery for Survivors of Torture.  Tel Aviv: UNHCR, 2016.

Losing, Loss and Living

Losing, Loss and Living

Jesse James will forever live in infamy.

No, not that Jesse James.  He already lives in infamy.  I mean the tight end Jesse James, number 81 for the Pittsburgh Steelers.  You know, the guy who caught the touchdown pass that finally put an end to Tom Brady’s decade-and-a-half dominance of the Steelers and cleared the way for a run to a seventh Lombardi Trophy.

At least for five minutes, he did.

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Visiting Maimonides

Visiting Maimonides

If Moses Maimonides were alive today, what would he think of a doctor who visited his grave to seek inspiration?

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Who You Callin’ Riffraff

The following post was originally a “d’var Torah” (the proper Hebrew term for a sermon) I delivered to my congregation on June 2, 2018.  I’ve added some examples, removed others, and taken out many of the specific citations.  If you’re interested in reading the original, email me at weinkle@healerswholisten.com and I’d be happy to send you a copy.

Only in Israel.  During the 1999 Israeli elections, actress and singer Tiki Dayan, known prior to that point for several Shakespearean roles and as the narrator in a Hebrew-language production of Joseph and the Amazing Technicolor Dreamcoat, took the stage at an artists’ conference where Labor candidate Ehud Barak was scheduled to speak.  In her speech, Dayan used an epithet straight from the Torah to describe the supporters of Barak’s opponent, the once-and-future Prime Minister Bibi Netanyahu, calling them “asafsuf min ha shuk.”

“Riffraff from the marketplace.”

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Make this Right

Make this Right

A few days ago I upgraded my mobile phone.  I transferred years of accumulated data and apps in nearly seamless fashion and can now unlock the thing with my face.  Yet the most amazing thing I witnessed in the process of purchasing this magical device had nothing to do with technology.

A man in a t-shirt and sunglasses appeared in the doorway of the store where I was making the exchange and called out to the store manager.  “Hey, you got a minute?” he yelled to the tall, bearded guy telling me how much I was overpaying for my service plan.  “I need to make this right.”

The “this” that he needed to make right turned out to be the loose ends of a heated exchange he had with the manager perhaps an hour earlier.  At some point in that conversation the fellow with the shades hurled a couple of expletives and the bearded guy – who responded by tossing him out of the store.

“Take your time,” he said now.  “I just gotta make this right.  I’ll come back when you’re done.”  He was, amazingly, hell-bent on apologizing for his language, and letting the manager know how sorry he was.

He’s my new hero, because I know how hard that was for him. 

If you are a primary care doctor, I advise you to set a life goal of never needing to be in your practice manager’s office with a patient – it is a surrogate marker of a complete communication breakdown.  But a while back, I found myself in my practice manager’s office with a person I’d been taking care of for years. 

Over the course of three days they had been on the phone with half-a-dozen people in my practice, from reception staff to medical assistants to nurses and finally the practice manager, asking for a refill of a medication in a dose that didn’t match anything on their medication list.  In fact, that medication did not even come in the amount they were asking for.  Over and over my co-workers sent me tasks asking for clarification – and over and over I repeated what they already knew to be true: I am absolutely certain of the dose of this medicine, I am not prescribing more than this amount, and I already sent in a prescription for the previous amount.

When my firm stance didn’t change the patient’s mind, they went to the practice manager, who got involved to stop them from screaming at the front office staff.  About to enter a room to see a scheduled patient, I decided to take a detour to the office, thinking I would stride in, put my doctor foot down, show the person the error of their ways and extract an apology to the staff, who were feeling abused and demoralized.

I casually opened the person’s chart, brought up the medication list and pointed triumphantly at the screen.  “See, look right here!  It says….”

I trailed off into silence.  An old prescription for two pills a day of the next to highest dose of the medication, adding up to precisely what the patient had asked for, stared me in the face.  All it said “right here” is that the patient was right all along and I was in such a hurry to get on with my day I hadn’t read the record carefully.  I even had a letter on file from the specialist who had recommended this unconventional dose but was no longer able to prescribe it themselves.

This time I was the one who dropped the unintentional expeletive.  “Oh ****, __________, I’m sorry.  This is my fault.  You were right and I trusted my memory instead of looking more carefully.”  I got the front staff their apology, though – from me.

If you read my work regularly, you know I sit in synagogue every week waiting for that sudden connection between what we’re reading from the Torah and what’s going on in my work life.  Primary care medicine is an endless uphill climb, and if there’s one thing I can grab onto each week then it was worth getting myself to shul that day.  This morning I was struck by one line in particular:

“When a man or woman commits any wrong toward a fellow person, thus breaking faith with God, and that person realizes their guilt, they shall confess the wrong they have done.  They shall make restitution…”

Some context: this portion of the Torah contains difficult material.  It has the very disturbing trial by ordeal of the adulteress, and the somewhat perplexing rules for taking a Nazirite vow.   But for me, the most difficult part of the reading is the line I just quoted – not difficult to understand, but to follow.

Admitting error, and then making restitution for it, is so hard that there are entire sectors of the economy devoted to avoiding it: risk management consultants, malpractice defense attorneys, K Street lobbyists.  Both practicing medical professionals and the industries that supply our tools are equally guilty of trying to deny responsibility and dodge confessing our mistakes.  Google Vioxx, or Dalkon Shield, and see what comes up.  Or ask someone who has endured a missed diagnosis, a medication side effect that was minimized by the prescriber, or even the blackballing, gaslighting, and harassment that sometimes follows the application of the label “difficult patient” to someone who challenges the unthinking routine.  We don’t like having our errors pointed out to us, and we enjoy even less having to fess up to committing them, and least of all having to fix the damage we did – so we do whatever we can to get out of it.

I spent part of my afternoon reading the new book Compassionomics, by Cooper University physicians Stephen Trzeciak and Anthony Mazzarelli.  I had been reading the first few chapters last weekend, patting myself on the back because the research they were reviewing, demonstrating how indispensable compassionate behavior is to the practice of sound medicine, is some of the same research I accessed in writing Healing People, Not Patients, and read like a validation of everything I stand for.

Today’s reading was way more uncomfortable.  Discussing the effects of burnout on medical residents, Trzeciak and Mazzarelli identify a long list of behaviors that lack compassion: not fully answering questions, prescribing medication for agitated patients without going to assess them, or skipping diagnostic tests because they might delay discharge.  I squirmed on my previously comfy couch; I could recall doing all of those things as a resident, sometimes even down to being able to picture the nurse, the specific unit of the hospital and the patient’s face.

Then I turned the page and read the story of Gina, a woman who asked her cardiologist for a sleeping medicine because of anxiety over an upcoming, non-heart-related surgery.  When the cardiologist probed deeper, it turned out that Gina had already asked her PCP, who had waved off the request by telling his staff, “If the surgery is the reason she can’t sleep, tell her to ask the surgeon to prescribe it.”

Forget about recalling something I did in residency that I’m not proud of.  I’ve done the same thing as that burned out PCP three or four times this month.  And I know as I’m doing it that I could make more of an effort.  Reading the book today was like having a mirror held up to my actions, like the Biblical prophet Natan telling King David, “You are that man!”  You, Dr. Weinkle, are that burned-out, uncaring PCP.  Do a better job!

Trzeciak and Mazzarelli are making the point that I’ve made dozens of times: there are behaviors that show, rather than tell a person, “I care about you and about what happens to you.”  Every time we turf one of those behaviors to a colleague, it lessens that message of caring (and according to their review of the research, there is often a dose-response effect – the more times we demonstrate a lack of caring, the worse our effect on their outcomes!).

Admitting error is one of those behaviors.  Admitting an error says, “I did something that hurt you and I don’t want to hurt you.  I feel sorry for causing you pain and now it is my responsibility to fix that pain.”  Like most broken things that become stronger in the repair, I have relationships with people I take care of that are more enduring now because of apologies and restorative gestures than they were before the mistake was made.  And these don’t need to be malpractice level errors, either.  The foul can be as minor as saying I would look something up and not getting around to it – a kind of mistake I am currently drowning in, as a chronic over-promiser.

So I need to stop turfing those requests to fill medications that are “someone else’s problem.”  I need to take the time to hear the problem before prescribing a med, even in the middle of a busy work day or of a sleepless night.  I need to deliver on my promises and not just make them to sound like I care.

I need to make this right.

The Doctor’s Decalogue

The Doctor’s Decalogue

One of my favorite journal articles of all time is Goldman, Lee, and Rudd’s seminal “Ten Commandments for Effective Consultations,” published in 1983 in Archives of Internal Medicine.  I love it because the Fifth Commandment is “Thou shalt make specific recommendations,” but also because it proves that even cardiologists count on their fingers – after all, isn’t the number of digits on our two hands the whole reason the entire world runs on a decimal system?

There are lists of ten everywhere, from David Letterman to the Bill of Rights.  My sons are constantly making lists of the top ten best athletes in every sport, and then arguing about them as though there is one “right” answer (“How can you say Paul George is any higher than number 7!?!”).  Even Hamilton and Burr had “Ten Duel Commandments (more on those later).”

Tomorrow night begins the Jewish holiday of Shavuot – the agricultural season of first fruits, and seven weeks plus one day since Passover, but, most importantly in today’s world, also the time of the giving of the Torah.  In other words, it’s Ten Commandments season.  So today I bring you a Ten Commandments of Healing, paraphrasing the original ten in a message for those who bring healing and comfort to body and spirit.  Get your fingers ready:

One: “I am Adonai your God, who led you out of Mitzrayim (the Dire Straits) to be your God.”  Our job, our direction, our North Star, is the goal of bringing people out of distress to a place of wholeness, to being able to shed the sick role and be themselves again.  Insofar as we, the healers who come from many traditions to join the community of those who heal human beings, have a common form of worship, it is to see and honor the divine spark within those we treat. 

Two: “Do not make yourself a sculptured image.”  Healing isn’t about the multi-million dollar clinical campus, or the new MRI machine, or the da Vinci robot in the operating room.  It’s about the person with the illness.  One of my mentors in medical school (can’t recall which one) used to say that modern medicine in America suffers from an Edifice Complex.  It’s only gotten worse in the last twenty years.  Honestly, I do my best healing in someone’s living room, and my mood and productivity is much better when I see the sunshine, something that is impossible to do in my two mostly underground offices or the vast majority of hospitals.

Three: “Do not swear falsely by the Name.”  I have had enough of advertisements for hospitals claiming they do patient-centered care but make everyone schedule their visits through an off-site central scheduler, place barriers between people and their own medical records, cancel visits for patients with limited English when an interpreter can’t make it and the provider “doesn’t like to use the phone,” and dozens of other decidedly non-patient-centered inconveniences and cruelties they inflict.  If you are patient-centered, then be patient-centered, don’t just say it.  If you do something that is not patient-centered, admit it and apologize.

Four: “Remember the Sabbath day and keep it holy.”  “Sabbath” (“Shabbat” in Hebrew) means “cessation.”  Hospitals work 24/7, and yet you know when it is after hours or the weekend.  Translator phones, transporters, ultrasound techs, and care coordination suddenly become very hard to come by.  If you work at the VA, reasonably healthy men with no reason to remain in the hospital will spend the weekend as guests of the federal government because there is no van to take them the five hours back to Clarksburg, WV until Monday (Tuesday, if it’s a holiday weekend).  “Remembering” the Sabbath is easy. 

Keeping it holy?  That’s another task.  One of the causes of healer burnout is the feeling that we can never stop, never turn off who we are, never be “out of the office” completely.  I am feeling guilty just thinking about the fact that I have a vacation coming up where I will be far enough away that I really can’t be available.  Yet without that cessation, we use up all of our emotional reserves.  One Jewish tradition holds that at the beginning of Shabbat we each receive an extra soul, a neshama yeteira, spare breath, that departs us when the Shabbat ends.  The Havdallah service marking the end of Shabbat includes the smelling of spices which is supposed to sustain that spare breath for a little longer, to help us make it through the always-challenging return to the secular week.  Giving ourselves that extra breath is not just healthy – it is a commandment that allows us to provide good healing.  When life is in danger, we are allowed to trepass this commandment in order to save life.  If we do not follow this commandment at other times, our own lives, and those of the people we care for, may be in danger.

Five: “Honor your father and your mother, so that you may long endure on the land.”  In Pirke Avot, the book of the Mishna that showcases the collective wisdom of the Rabbis of Roman Palestine, Rabbi Akiva says (verse 3:14), “Beloved is a human being, for they were created in the image of God.”  He goes on to explain that one way in which we know they are beloved is that a “precious vessel” – the Torah, God’s teaching – was given to them. 

What is our precious teaching?  The knowledge of how to heal, both the science and the caring.  We are blessed to be living in the 21st century, when medicine has begun to separate itself from the days when it was brutal, harmful, and based entirely in superstition and dogma.  At the same time, our precious teaching is in the wisdom and courage of the greats who came before us: Osler, Dame Cicely Saunders, Schweitzer, Hawa Abdi.  Akiva quotes from Proverbs 4:2, “Behold, a good teaching has been given to you, my teaching, do not abandon it.”  Even as we question, challenge, and refine our received wisdom, we should continue to hold the essence of this received tradition of caring close to our hearts.

It’s tempting to think, in each generation, that we know better than those that came before us.  Yet the doctors who first prescribed morphine in the 19th century recognized opioid addiction as a disease that they had caused, and responded with concern and compassion.  Did the ensuing generations who stigmatized and criminalized that addiction, and adopted a “blame the victim” mentality, really know better than their forebears?  Or the generation of doctors who have done millions of unnecessary tonsillectomies, cardiac stents, or sinus surgeries, only to discover that the “less is more” restraint of earlier generations was the right way when the hard evidence finally came out?

Six: “Do not murder.”  One of Burr’s commandments concerns having a doctor on site: “Have him turn around so he can have deniability.”  We don’t participate in duels anymore.  But what about the ways in which we know, if we care to look under the surface, that we endanger lives?  I had a houseguest a couple weeks ago who was not medically trained.  She found a book on my shelf by James Lieber entitled Killer Care: How Medical Error Became America’s Third Largest Cause of Death, and What Can Be Done About It.  She was horrified!  Yet we persist in bad, unsafe habits from not washing our hands to not adequately staffing high-risk areas of hospitals.  We insist on using medications which are ripe for complications and bad interactions long after alternatives exist.  We prescribe “palliative chemotherapy” in the face of evidence that patients with stage 4 cancer enrolling directly in hospice actually live longer (and better) than those getting disease-directed treatment.  If we read the evidence, it’s clear that we can no longer “have deniability,” whether for the opioid crisis, unsafe surgeries, or anything else.  We need to take responsibility for the harm we do, not just the healing.

Seven: “Do not commit adultery.”  Where do our loyalties lie?  With the people we care for?  Ask yourself how many times you’ve “cheated on” one of those people, just a little, with a pharmaceutical company who got you to prescribe a different drug?  Or with a research project that turned a person into a subject, suffering into a statistic?  Or with the protocols set for you by a hospital system, an insurer, or someone else who did a wallet biopsy and found your patient (or your treatment plan) to have unfavorable financial markers?

Eight: “Do not steal.”  People’s time, keeping them waiting, bringing them back for “routine” visits and treatments that don’t add life or wellness.  People’s money, prescribing a $50 dollar drug when a $4 one will do.  People’s hopes, either by building up pie-in-the-sky expectations and not being honest about the bad stuff, or by dismissing someone out of hand as hopeless instead of listening and trying.

Nine: “Do not bear false witness against your neighbor.”  We have a bad habit of gaslighting our patients: labeling them drug-seekers, somatizers, malingerers.  Or labeling their diseases with wastebasket diagnoses, telling them there’s nothing wrong with them.  While it’s important not to violate Commandment Eight by overpromising cures and clear diagnoses, it is equally important for them to feel heard and believed when they say it hurts – and not to bias other providers about them to the point where they don’t listen.

Ten: “Do not covet . . . . anything that is your neighbors.”  We have a sacred gift, being entrusted to heal.  Keep that front and center.  Ignore the shiny objects, the lifestyles that are supposedly better or cushier.  This is where you belong – be grateful for the opportunity.

What are your Ten Commandments for healing?

Don’t Be an Adler

SPOILER ALERT: If you are even farther behind the times than me, this post will ruin a small subplot from Season 2 of the Amazon Original Series, The Man in the High Castle.

I know what Nazi doctors like Józef Mengele did in Auschwitz, but that does not make it any easier to stomach Dr. Gerhard Adler.  Adler is the “kindly” old physician in the Amazon series The Man in the High Castle, the disturbing alternate reality drama in which the Nazis and Japan won World War II and divided the United States between them.  Season 2, Episode 3 finds Adler in a well-appointed study on Long Island, pronouncing a death sentence.

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The Wall of Water

The Wall of Water

In the past month I have offered an oncology consult to a woman whose cancer was diagnosed eighteen years ago and declared cured thirteen years ago – a Jewish lifetime since diagnosis and long enough for a child to reach the age of Jewish maturity since her oncologic cure.

Such is the world of chronic illness.  We don’t let ourselves think in terms of cure.  We don’t let ourselves say we have had cancer, or had mental illness, or had lupus, but rather we are defined by them.  We are living with schizophrenia, suffer from lupus, or at the best we are cancer survivors.  The cancer is gone; it’s mark on us is indelible.

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