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.

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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

Thinking Too Much?

Thinking Too Much?

It’s Thanksgiving Day and my house is bursting at the seams – and this isn’t where we’re having dinner.  Even with runny noses and upset tummies – and standing in the cold waiting for one of my children to cross the finish line of the Turkey Trot – there is love and warmth everywhere.

That’s not true.  Not everywhere.  Caren called my office this week to refill her blood pressure medication, and she was in a foul mood.  “My family doesn’t want me around for the holidays.  This season is really hard for me.”  Later that same afternoon, Michael, an anxious man in his early thirties, confided in me that he was trying hard to stabilize a housing situation that was beyond his means, “but it’s really tough – I have no one to lean on and I’m doing this all myself.”  They are not feeling the love.

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Thought Bubbles

Thought Bubbles

I had a sobering exchange Sunday afternoon with a new friend.  We had met recently at a conference and we were talking about suspicion and distrust between doctors and patients.

“I’d love to do a presentation showing the little thought bubbles above the doctor’s head,” he laughed.  “You can’t possibly be paying attention the whole time.”

I didn’t have to answer him for him to know he hit the nail on the head.  We can’t possibly be paying attention the whole time.  I know the feeling of distraction all too well – from extreme fatigue, from worrying about how far behind schedule I am, from ruminating over a bad interaction with the previous patient, or most recently from massive emotional trauma (see the “Three Healers Who Listen” posts from earlier this month). Read More

Loving the Label

One of the first “sermons” I ever gave was for student High Holiday services in 1993.  I spoke about a camper I had worked with more than once, a kid who had always been marked as a “bad kid,” but in whom I had found a sweet demeanor and a fascinating personality.  He was really coming around – until he stole money out of another kid’s wallet.  “No more tears,” I pleaded with him in the sermon.

I don’t know what made him decide, at that moment when he was finally shedding his troubled image, to lift five dollars from one of his bunkmates.  But I know I see this kind of thing happening often in my work – and the stakes are a lot higher than getting sent home early from camp.

Twice recently, I’ve heard from people I care for who have months or even years of sobriety to their name, but the image, the label just won’t go away.  Either they are still surrounded by the people and situations that facilitated their substance dependency in the first place, or they continue to be stigmatized in the present for behavior in the past.  Read More

Three Healers Who Listen – Dan

Three Healers Who Listen – Dan

My siddur, my prayerbook, is now part of a crime scene, a killing field.

The slim, cloth-bound, all-Hebrew book is called Va-ani T’filati, “I am my prayer,” and was the one I carried with me in the same bag as my tallit and tefillin wherever I took them.  On October 20, I returned home from celebrating our friends’ daughter becoming a Bat Mitzvah in the Tree of Life sanctuary to realize that my bag felt lighter than it should.  About one small, hard-cover book lighter.

It was, of course, in the book rack on the back of the pew, in the center-left section of the sanctuary about 10 rows back, just where I left it.  No worries.  I had a busy week, but on Thursday, October 25, I remember to e-mail the Tree of Life office to ask if someone could locate it.  I would pick it up . . . later. Read More

Three Healers Who Listen – Rich

Three Healers Who Listen – Rich

The Hebrew letters often hint at a common object: bet hints at bayit, a house.  Gimel hints at gamal, a camel.  And shin?  Why, shen, of course – tooth.

I like to think that the reason for this is that shin, or rather sin, which is the same letter with the dot moved to the other side, is also the first letter in sameach, happy.  And what do we do when we are happy?  We smile and show our teeth.

My colleague Rich Gottfried smiled all the time; as people spoke at his funeral, or around the office this week, almost all took note of his smile.  He was the Hines Ward of dentists, it would seem – always smiling. Read More