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Oasis In Time

Originally published January 17, 2022 at https://blogs.timesofisrael.com/oasis-in-time/

The late Yogi Berra once said, “It ain’t over ‘til it’s over.”  Like most things Yogi said, his famous quotation was a malapropism, a fumbling of a more conventional truism about a particular individual belting the notes that mercifully signal the end of an opera.

But what do you do if there’s no one to sing, no signpost to tell you the end has arrived?

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Keep Your Religion In Medicine

I was on suicide watch for a patient a few years ago.  After a long series of emails and text messages and phone calls, the psychiatrist, the therapist, the patient and I were all satisfied they were safe.  After the dust settled, I mentioned to the therapist that I had recommended a book to the patient by Rabbi Naomi Levy.  “Are you mixing religion and medicine?” she texted back.

“That’s my brand…” I replied. 

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Darkness and Dawn

Parashat Bo 5782/January 8, 2022

The beginning of Parashat Bo feels like the kind of long slide into the abyss I wrote about two weeks ago.

With the plague of fiery hailstones just ended, God sends the locusts.  “They shall cover the surface of the land, so that no one will be able to see the land. They shall devour the surviving remnant that was left to you after the hail,” Moshe and Aharon warn Pharaoh (Shmot 10:5). 

In the months after the October 27th, 2018, terror attack in Pittsburgh, I had one consistent source of solace, the site of the last hopeful thing that happened to me immediately before the attack: the newborn nursery, where scarcely an hour before the shooting started I made my rounds with my tiniest, most precious patients.  I was often late to work those months, lingering extra minutes in each room, snuggling every baby for no reason other than to bask in the calm of a sleeping newborn.  I would leave the house for rounds some days and tell my wife I was going to therapy.

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Blood in the Water

December 31, 2021/27 Tevet 5782, Parashat Vaera

Originally posted at https://blogs.timesofisrael.com/blood-in-the-water/

Early in the pandemic, we said and did a lot of things that made little sense.  Recommendations changed almost daily.  We gravely took specific precautions that turned out to be useless, like hanging plexiglass shields and buying stores out of toilet paper.  And we talked a lot about “silver linings,” like how glad we were to take a break from working in offices or wearing dress clothes.  Twenty-one months on, the recommendations still change faster than we can keep up with, precautions we thought we finally had figured out now turn out again to be minimally effective, and the only silver lining I see is in my hair.

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Wood, Fire and Water

Parashat Shmot 5782, 20 Tevet/December 24, 2021

It was the smokiest backyard fire I have ever built.

We had an unseasonably warm, dry day in the middle of last week.  Through sheer force of will I caught up on work, cleaned up after the dog, and hauled out the fire pit one last time before winter.  We still have an enormous pile of cut firewood from the limb of our neighbors’ tree that crashed into our backyard on June 13th, sitting unused due to an excessive amount of rain, stress, and general exhaustion that has kept us from using it.

Unfortunately, the kindling, “dry leaves” that I had gathered in armfuls from the yard, wouldn’t light.  Only the tops were dry; the lower surface where they had been in contact with the grass was wet and already composting in place.  This didn’t become clear until they were already on the fire.  I managed to salvage the endeavor by finding some newspaper indoors (not easy in 2021 – we’re reduced to burning junk mail coupons), but what resulted was a roaring fire that gave off so much smoke I was still smelling it the next day inside a facemask that hadn’t even been next to the fire.

Building that fire was part of my attempt to climb out of a well of depression, the latest in a series I have experienced since the start of the pandemic.  I wasn’t just building fires: I was playing music, finishing a collaborative piece of writing I’d been working on with Rick Light, even going out a few times to places that were vigilantly checking vaccine cards.

And then I got Omicron.

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What We Keep and What We Leave Behind

A joint post on Times of Israel with my friend Rick Light of Kavod v’Nichum and the Gamliel Institute about how the pandemic has changed some of our oldest rituals – and how it hasn’t changed them. While we write about burial practices, we are really talking about why all of our rituals and routines are the way they are, even in the most non-routine of times.

https://blogs.timesofisrael.com/what-we-keep-and-what-we-leave-behind/

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

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.

Copyright © 2022 Jonathan Weinkle. All rights reserved.