Lifeworld Turned Upside Down

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

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

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

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

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

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

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

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

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

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

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

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

If Jethro Ran Your Hospital

If Jethro Ran Your Hospital

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

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

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The Worry List

The Worry List

Yesterday was a fast day.  Which is not to say that it went by quickly, but that, for religious reasons, I did not eat.  The prayer that an individual says in the afternoon service on a fast day, within the final hour or two before eating, says, “Be near to our cry.”  It quotes a verse from Isaiah 65 where God says, “Before they call, I will answer; while they are still speaking, I will hear.”

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Kindling… (#notaChanukahpost)

Kindling… (#notaChanukahpost)

Somehow, while I wasn’t paying attention…

The Kindle edition of my book is ready! Healing People, Not Patients is now available in e-book format on Amazon. If you or someone you know has gone paperless (or run out of shelf space, as I have) but wants to have a copy, now you can!

One Small Step

One Small Step

There’s a talmudic tradition that when a person takes their first steps in the morning, they should recite the blessing, “ha-meichin mitzadei gaver” – “who prepares a person’s steps.”[i]

Recently, I learned a new understanding of this prayer, and a new occasion on which to say it.  When one is uncertain, afraid, or overwhelmed, ha-meichin mitzadei gaver is a prayer to be shown where to place one’s feet next, to have a clear path appear.  In the traditional instance, the word gaver means “person,” but here it suggests to me gevurah, strength or fortitude.  “Blessed are you, God, who prepares a sure path, who makes my steps sturdy.”  I also think of the verb le-hitgaber, to overcome.  “Blessed are you, God, who shows me the way to overcome.”

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Twin Cities

New material will be coming shortly, but in the meantime please check my events page for the details of my trip to the Twin Cities in a couple weeks! Many thanks to my cousins Rabbi Jeffrey and Dr. Deborah Schein for their hospitality and to Liz Rappoport, SaraLynn Newberger, Susie Held, and Rabbi Alexander Davis for bringing this together!

Cutting Ties

Cutting Ties

I spent the morning of October 27, 2019 taking down my sukkah.

Not my sukkah, but this is what a sukkah looks like. From

Leviticus 23:42-3 tells us that God commands us to dwell seven days in the sukkah so that future generations will remember that God made the Israelites dwell in sukkot when God redeemed them from Egypt.  Rabbi Adin Steinsaltz comments that this period in Jewish history is like the childhood of the nation, quoting Jeremiah 2:2:

“I counted in your favor the devotion of your youth, your love as a bride; How you followed me in the wilderness in a land not sown.”

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Here We Sit Again

It is late Friday afternoon. 364 days ago, blissfully unaware of the awful events that would take place the next morning, I went to welcome the Sabbath Queen with joyous music, resounding off the walls, floor and ceiling of the lobby of my synagogue. You can read the story of that night, and the day and month that followed, in my earlier post “Sitting In the Valley of Tears.”

That night, October 26th, 2018, I imagined that the words of Lecha Dodi could heal a soul broken by unimaginable horror, unable to reintegrate despite years of distance from the event. In the year since I have had occasion to wonder whether I myself don’t find them to be mocking me.

And so I share these words with you now. I am beginning to feel I can sing again, and someday soon they will have music. They hurt me to write, they are a chore to read and a burden to sing, but the song must be written and sung. May they serve you well, and may they help to strengthen the memories of my 11 friends and neighbors.

“You have sat long enough in the vale of tears;

God will have compassion on you.”

We have sat too long in the vale of tears.

God will have compassion on us.

Sadness is a valley, crying a wide rift

And the rift of our tears is still deep

The wound is open, the soul injured

Who can say now we have sat long enough?

In a moment of haste You hid Your face

And in that same moment everything changed

With eternal lovingkindness reveal Your mercyThen we will no longer sit in the vale of tears.     

רב לך שבת בעמק הבכא

והוא יחמול עלייך חמלה

רב לנו שבת בעמק הבכא

והוא יחמול עלינו חמלה

הצער הוא עמק, הבכי הוא בקעה

ובקעת דמעותינו עוד עמוקה

הפצע הוא פתוח, הנפש פגועה

ומי יגיד עכשיו שרב לשבת בה?

שצף קצף הסתרת פניך

ובאותו הרגע הכל כבר השתנה

בחסד עולם גלה רחמיך

ולא נשב יותר בעמק הבכא

One Thing I Ask

One Thing I Ask

If you could only ask me one question, what would it be?

It sounds like a party game, a conversation starter designed to get people talking at a speed dating event or a team-building exercise.  But sadly it’s the way most people’s encounters with their healers go these days.  For all practical purposes, there is a “one question per visit rule.”  Better make it a good one.

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