Answered Prayer?

Answered Prayer?

In Hebrew the word for “answer,” teshuva, comes from the same root as the word “return,” shuv.

So when someone returns a prayerbook to you, is it an answered prayer? You remember the one – the one I thought would never come back, the one that was a silent witness to a massacre. It came back to me this week, wrapped in white archival paper and tied with a string. My most heartfelt thanks to Eric Lidji, from the Rauh Jewish Archives, for putting the pieces together when he read my previous post about it and realized he had seen the book.

I am praying from this book again, feeling like it is possible to once again feel that I am my prayer. I am hearing by email from the friend who I prayed for in that piece. I am able to feel hope again.

I see people every day who were broken by tragedy, devastated by illness. sometimes decades ago. This week I feel like even for them, there is still hope we can return them to wholeness. We can give them an answer. The world may never be the same – but it will be better than it is now.

The Empathy Switch

What position is your empathy switch in?

I’m a few chapters into Brian Goldman’s new book, The Power of Kindness, about his journey to figure out what happened to his capacity for empathy over a career as an emergency physician.  Goldman’s first stop takes him to some researchers from Laval University in Quebec, who tell him that everyone empathizes – that it’s natural and instinctive for human beings to feel what others feel.

Read More

Dire Straits

Dire Straits

We exchanged a series of sheepish looks as she spoke – Kelly with me, me with her daughter, her daughter back to her.

“Everything on the left side – first the neck, now the leg, what’s next?  The stomach?  The kidney?”

She was wrong, though.  There had been a problem, the right shoulder and neck, with almost the same symptoms.  This went away, then the identical complaint returned in the other shoulder.  I reminded her of this.  We all laughed, but it did not ease the frustration for any of us.

“You’re right.  I just seem to get better from one thing so something else can go wrong.”

I’ve always been captivated by the power of the Exodus narrative as a parallel for illness.  The Exodus from Egypt is crucial to understanding the Jewish take on the world, but there is a certain universal appeal.  In the first chapter of Healing People, Not Patients, I recall how my teacher, Rabbi Larry Heimer, introduced me to an interpretation of the Exodus by Rabbi Yitz Greenberg that shaped how he, and in turn I, thought about illness.

The Hebrew for Egypt, Mitzrayim, is the equivalent of the English, “in dire straits” – stuck in a narrow place from which escape seems impossible.  Greenberg explains that by being in bondage in “Dire Straits,” the Israelites were in a state that God never intended human beings to endure.  Slavery is not the natural condition of humanity.  The Exodus, in turn, is proof that when humanity suffers, God hears, and God cares, and God acts.

Modern humans stand in for God in acting to relieve each other’s suffering, including getting each other out of dire straits.  The Exodus imagery is supposed to remind us that healing is possible, and that we are supposed to reach out our arms and perform some signs and wonders of our own to make it happen.  Modern medicine is nothing, if not signs and wonders galore.

But chronic illness confounds the metaphor.  If illness in general is Mitzrayim, then chronic disease is Pharoah.  “I’ll let you go.  On second thought….  Naaaah, changed my mind.  Back to work!  Build those pyramids!” 

The plagues are powerful medicine, to be sure.  “Frogs?  No, not frogs!  I give!  You can go!”  But no sooner do the Israelites start packing to leave than Pharoah has another change of his hardened heart.  Kelly can relate; every time we unleash a good plague of muscle relaxers on one pain, her personal Pharoah comes back with a vengeance in a different limb. 

If you don’t believe Kelly, ask Yuri, ready to return to work after a long illness, smiling and hopeful in my office one week, only to return two weeks later because the dizzy spells returned after only three days on the job.

Or ask a cancer survivor, finally daring to dream and plan again after 4 ½ years of living scan to scan, who learns of a spot on the 5-year scan that means he is back to square one – only with fewer options.

Ask a person finally ready to cut the cord from medication after a long journey with depression, only to find herself on the edge of the precipice once more after the unexpected death of a close relative.

For the person living with chronic illness, there is a problem with the Exodus narrative.  For all that God promises, that doctors like me who have a hard time remembering that we are not God promise, and for all that we may deliver on some of our promises, at the end of the Exodus from one sickness, after the crossing of the Red Sea that is the ringing of the Mayo Clinic oncology bell, the return to work, the dancing at a wedding, for all that, the true end result of the Exodus is to find yourself wandering in the desert for 40 years, relapsing and remitting, having good days and lousy ones, until someone who is not you eventually gets to see the promised land of being chronically well.

A couple of nights ago, I participated in a Twitter chat called #medhumchat, discussing the poem “Intensive Care” (and if you like what I write you should participate too; shout out to Colleen Farrel, MD, aka @medhumchat for coming up with this).  The poet likens the ICU to a ship adrift at sea, with no instruments – even though the ICU has instruments coming out the wazoo (sadly, both literally and figuratively).  It is the kind of ship likely to end up stuck in a narrow place – to be caught in Dire Straits.

I’m not sure how to change this story.  The Israelites of the original Exodus wandered because they were still stuck mentally in their narrow place, never truly believing they had the agency to be free.  I think we may be making the same mistake – so stuck in the narrow place of a disease model that envisioning well, especially sustained wellness, is impossible for us. 

How else to explain my shock when I meet a person over 80 who tells me they take no regularly scheduled medications?  How else to articulate why I get worried, not happy, that someone I care for frequently drops from the radar for 2 or 3 years?  It couldn’t, God forbid, be that they are well – there must be something terribly wrong that isn’t getting my attention, right?

The way to change the story, I think, is to realize there’s another way to read the analogy.  Yes, the person with the chronic illness is like the Israelites in Mitzrayim – but so is the healer.  Until we healers learn to stop saying, “No, you’ll need to take that medicine for the rest of your life, side effects or not,” or to stop telling people to cancel vacations and grand plans, or to stop acting like the purpose of old age is to stay safe instead of to live, we are all destined to be stuck here in Dire Straits.

At least they have a good house band….

The next #medhumchat will be at 9 pm on January 16; search the hashtag on Twitter to find out which readings Colleen has chosen and join in!  I found it a great antidote to my own Dire Straits – a really good way to read situations differently.

First Podcast!

I’m very excited to announce that tomorrow, January 2, 2019, I will be the guest on the next episode of the Pitchwerks podcast, hosted by Pittsburgh’s own Scot MacTaggart. Scot and I discuss how being a “healer who listens” goes beyond just being customer service, whether honoring someone’s humanity means I can’t say “no” to a request, and what comes next now that Healing People, Not Patients is published. Please listen in, and thank Scot for me by liking and subscribing to the podcast, which features weekly interviews with people who are not only doing well, but doing good. Special thanks to my longtime friend Russell Goldstein for making this awesome connection.

UPDATE 1/2/19: The podcast episode is now live! Click here to download or listen online, and don’t forget to do Scot a solid and subscribe while you’re on the page.

Names

People don’t give names enough credit for having power.

You’ve all been on the playground as kids and either said or heard, “Sticks and stones may break my bones, but names will never harm me!”  Shakespeare, who named hundreds of characters in his career, didn’t even have much use for names: “What’s in a name?  A rose by any other name would smell as sweet.”

Let me tell you, names have power.

Read More

For a Reason?

Know your audience.

I had a great blog ready to go for today, super-insightful.

Then I looked at the calendar: December 23rd.  Just another day for me, but for at least some of you, two days before Christmas – the most joyous day of your entire year.  The fantastic blog I had written about confronting the fear of death suddenly seemed tone-deaf.  It will just have to wait until next year (hooray for lunar calendars).

The other interesting thing in yesterday’s Torah portion was Joseph’s second attempt to reassure his brothers that God brought about all his suffering for a reason.

Read More

Bystanders and Stand-By-Hers

Bystanders and Stand-By-Hers

Even when you are a “Healer Who Listens,” there is a time to stop listening and speak up.

King Solomon, writing under the pen name of Kohelet (Ecclesiastes), said, “There is a time to speak and a time to be silent.”  Normally, this is excellent advice for doctors who have been shown in study after study to interrupt our patients after somewhere between 11 and 23 seconds after they begin speaking.

But what if you sit on the board of a health system that routinely engages in “upcharging” insurances? Employs physicians who routinely provide care that is marginal at best and unsafe at worst in order to maximize revenue?  Is more interested in patient “throughput”than human input?

Last Monday I sat with the combined boards of the Jewish Healthcare Foundation and its three operating arms trying to answer exactly this question.  How do healthcare boards, made up of powerful,influential, knowledgeable people in the community, suddenly become bystanders to all sorts of malfeasance by the hospitals and healthcare systems they purport to control?

You can guess at the answers.  People see these appointments as ceremonial rather than hands-on.  The group-think stifles dissent.  Medical providers on the board don’t feel qualified to comment on financials and the finance people don’t feel qualified to comment on clinical matters.  The financial bottom line is the real mission,regardless of the mission statement.

But one recurrent answer struck me: the way the whistle-blowers are ostracized.  Boards maybe passive bystanders, but there’s usually one squeaky wheel that speaks up.  You know the one – and you know what happens to their career afterward.

The phenomenon isn’t new. A famous story in the Talmud, which I had the opportunity to examine again this past week, tells of a new type of oven that is supposed to be constructed so that it cannot become ritually impure.  The problem is that the rabbis deciding whether it meets that standard all say that it fails – except for one, Rabbi Eliezer.

Eliezer tries every line of argument he can think of to convince his colleagues that the oven does what it claims.  When all logic fails, he resorts to miracles – rivers flowing backward, trees uprooting themselves, even literally bringing the house down.  The other rabbis hold fast, even when a heavenly voice calls out to them, “Eliezer is right!”  “It’s not up to Heaven anymore,” they say.

They don’t stop there, though.  They invalidate every ruling Eliezer has ever made on ritual purity and ostracize him from the community – and the consequences are dire, both for him and for the community, eventually leading to the death of the rabbi at the head of the group (this is the part usually left out of the story when it’s told in school).

What is missing from Eliezer’s story, and what is missing on bystander boards, is a second voice.  One person screaming about the evidence and the morality of a position, no matter how correct, is a nuisance and a crackpot. But as several people at the board retreat pointed out, a second – or God willing, even a third – voice, saying, “Hey, wait a minute, I think they may have a point,” changes the conversation. Are they both grandstanding?  Are all three of them over the rainbow?  Not as likely.

The Foundation, and particularly its Pittsburgh Regional Health Initiative arm, has made its mark in the patient safety movement.  A hallmark of that movement is listening when a patient, a nurse, a surgical tech, or a doctor says, “Hold everything, something’snot right here.”  Just as important is recognizing that the person calling a halt isn’t trying to sabotage the surgery or cost the hospital money – they are trying to prevent harm to a human being.

How much damage could have been prevented if one other rabbi would have said, “You know, Eliezer’s pretty smart.  Maybe we should take another look at this oven?”  How many lives could be saved if the next time someone states an uncomfortable truth at a hospital board meeting, someone would say, “You know, Dr. Jeremiah really knows her stuff.  We need a task force to look into this problem right now?”

Healers, our job, wherever we are in the system, is to be that second voice – not a bystander, but a stand-by-her, if you will.  Just like we need to avoid anchoring in our first diagnosis and ignoring the signs of some other brewing trouble, we need to avoid anchoring in the-way-we-always-do-things, or the-way-everyone-else-is-doing-things-now, and listen for signs of trouble in the system.  Everyone has an interest to serve – our interest is with the people we care for.

Curing Burnout

Curing Burnout

People often ask me about burnout, both colleagues and laypeople.  I appear to them to be asking so much of the healer, to give each day from the depths of their soul and to bring light into darkness.  How can I possibly keep from burning out?

Because when I need it most, the people I care for bring the light right back, that’s how.  On this last day of Chanukah, I thank everyone who has shared their light with me, no matter how much they were hurting at the time, to rekindle my own flame.  You are the reason my oil keeps burning, long after it should have burned out.

Conversation – the Wonder Drug

I “officially” launched my book, Healing People, Not Patients, Sunday night, the first night of Chanukah.  Over 100 people gathered to hear me read,sing and celebrate the idea of healing relationships based on listening to one another, not on business or technology.

So I was tickled the following day to hear this story on All Things Considered. A major study done in Switzerland concluded that for a large proportion of people currently recommended to be on statin drugs for cholesterol, a frank conversation with their doctor should be the first intervention, not a prescription.

Not only that, but a few weeks earlier, the American Heart Association and American College of Cardiology issued new recommendations on cholesterol calling for – wait for it – “more nuanced conversations around who would most benefit from statins.”

Now, I shouldn’t be too smug.  The AHA/ACC follow that recommendation by recommending yet another technological test, a coronary calcium CT scan, to help make the decision, and quote a suspiciously low price of $100 (not in my market, that’s for sure).  Not included in the price tag – the cost of evaluating and treating all the unlooked-for,incidental findings the CT happens to find while looking for calcified coronary arteries.

On the other hand, those results do promise to inform a conversation that could end up getting as many as 40% of patients who take statins off their meds.  It’s a trade-off.  And how do we decide what to do when there’s a trade off?

With conversation – the wonder drug that works wonders (hopefully Bayer doesn’t come after me for that line).

What’s the goal of treatment?  How bothered are you by a 2% risk of heart attack?  5%?  25%? What about stroke?  The answers are different for different people.  Tome, 5% means I am 95% likely to be fine, a near-certainty.  To someone else, it is a death sentence. 

Douglas White, a critical care doc at the University of Pittsburgh, has done some fascinating research about how, even when given the same statistic, families react to news of a poor prognosis in very different ways, depending on how those numbers sound to them.  Their father is a “fighter,” their mother went to church every week, their grandfather “told them his time had come and now we know he was right.”  Guidelines can’t resolve those differences – only the wonder drug of conversation can do that.

Years ago I heard the story of a rabbi who, on Friday afternoon, just before Shabbat, has two congregants come to him, one after the other.  The first brings him a chicken and asks if it is kosher.  He inspects it carefully, pronounces it damaged and unfit for use, and sends the woman on her way.

The second woman enters, also carrying a chicken, and asks the same question.  This time, as he turns the bird over and over, the rabbi asks the woman gently about her husband, her children, her home, and her relatives living far off.  He sees a problem.  He thinks for a few moments, pronounces the bird kosher, and wishes her “Shabbat Shalom.”

His student is perplexed. I’m sure my medical and physician assistant students can relate – they have seen me interpret the same set of guidelines in exactly opposite directions many times.

“The first woman was well-dressed and I know her to be of means – and meticulous in her observance. Her bird had a flaw that some might permit and some might not.  She would not want to take chances, and I know she has other food she can serve for Shabbat.  The second, I learned from our conversation,is in difficult circumstances.  If I disqualify her bird on a small technicality, she will have nothing to eat tonight,” explains the rabbi.

The plural of anecdote is not data, but the singular of guidelines is not person.  Guidelines are like an old paper map, good for planning your trip but not so good for improvising a route around an accident or a traffic jam. Until we come up with the Waze of guidelines, we will have to rely on the wonder drug of conversation.

I think NPR’s Wendy Wolfson sums it up best, in a March 2015 article on statins that is linked to this week’s story:

“My victory was in finally figuring out the right questions to ask. I’m still shaken because she had prescribed to formula but not to me as an individual. We both missed things in the risk conversations we should have had. Next time I hope to do better at asking questions like ‘Why?’ and ‘What happens in people like me?’ and ‘What are the alternatives?’

And of course, ‘Where can I look this up?’”

Be like Wendy – and if you’re a healer, be prepared with some answers for Wendy…

Special thanks to all who attended the release party at Repair the World.  Thanks also to Gideon Orbach, DC, for hosting me at the Winer Wellness Center this week, and to Scot MacTaggart, host of the Pitchwerks Podcast.  We recorded yesterday and the episode should drop in a couple weeks.  Stay tuned!

Sitting in the Valley of Tears

Sitting in the Valley of Tears

Shabbat evening, Friday, October 26, 2018.  I am sitting in the stone-floored lobby of my synagogue, afloat in music, feeling my week’s tension being carried away on a wave.

Leonard Cohen’s melody for “Hallelujah” is being transformed and elevated as we fill it with the words of “Lecha Dodi,” welcoming the Shabbat Queen.  I remember the exact moment at which I felt the release, the peace of letting go of everything that vexed me:

Rav lach shevet b’emek habacha – “You have dwelled too long in the valley of tears.” Read More