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.

So it should be some small consolation that even Moses fell prey to the creep of his job taking up every available moment.  He “sat as magistrate among the people, while the people stood about Moses from morning until night.”  I think of the couple of days I spent in Haiti ten years ago, when a crowd of desperate earthquake survivors came to the clinic I volunteered at and slowly bubbled forward until the three medical professionals on my team were pinned in the corner.  The next day a different group came back, and we tried a different approach to crowd control – and instead of a crush of people in Brownian motion we had a long line of people snaking out the door and down the road to the right more or less without end.  There was no third day; I nearly had a nervous breakdown and ended up leaving early.

Fortunately for the Israelites, they did not have to spend the next 39 years, 352 days leaderless.  Moses’ father-in-law Jethro came to the rescue.  Here too, I can identify, as I am no stranger to being chided by my father-in-law: “What is this thing you are doing to the people?  Why do you act alone, while all the people stand about you from morning until evening?  The thing you are doing is not right; you will surely wear yourself out, and these people as well (italics mine).  For the task is too heavy and you cannot do it alone.”[i]

There is no commandment that says, “Thou shalt delegate,” or “thou shalt be organized,” but Jethro speaks a fundamental truth.  Good intentions only survive to become good deeds when we somehow create space for ourselves to do those deeds consistently and well, and don’t use up all of our energy trying to do everything for everyone all at the same time.

There’s a principle in biblical interpretation that two concepts that appear next to each other in the text must connect in some way.  Jethro’s criticism, “You will surely wear yourself out, and these people as well,” links to two important verses that come earlier in the same chapter of Exodus.

In Exodus 18:6, Jethro sends word to Moses, “I am coming to you, with your wife and her two sons.”  The verse is a reminder of the fact that, Prince of Egypt notwithstanding, Moses did not take his nuclear family with him when he went back to Egypt to orchestrate the Exodus.  They had been waiting for him in the desert patiently, according to tradition possibly as long as 40 years, until he finished this monumental task he was working on.  And now, how does he celebrate the reunion?  By returning to work the next day from dawn to dusk to sit in judgment.  Jethro senses Moses headed for burnout, or else to lose his family forever.

At the very beginning of that chapter, Jethro first decides to go meet Moses after hearing “all that God had done for Moses and for Israel His people.”  I came across a comment on this verse a couple days ago that was music to my ears.  Rabbi Elimelekh of Lizensk, an 18th century Hassidic master, observed that Moses and the Israelites had two very different experiences of the Exodus.  For the Israelites, the Exodus was a miracle, wrought by God and saving them from their plight of slavery.  For Moses, raised as royalty and growing up free, participating in the Exodus was a choice, a conscious decision to go back to Egypt and serve the God that appeared to him in the Burning Bush.

Different experiences of the same event?  Why, Elimelekh is talking about “illness narratives” of the Exodus!  Each individual had a unique perspective that is unlike that of anyone else, even though they left the same enslavement, in the same country, crossed the same desert and forded the same sea.  Now, these hundreds of thousands of unique individuals came to stand before Moses to bring their disputes to him, and how does he reward them?  By trying to handle everything himself, ignoring his family and exhausting his energy.

How much attention do you think that Moses could pay to the uniqueness of each of those Israelites, to the subtle needs they might have that set one apart from the other?  There’s a classic story from a later time of a man who comes to the rabbi to ask if it is permissible to have four cups of milk at his Passover seder.  The rabbi responds by giving the man enough money out of the charity fund to buy an entire seder meal.  The students are perplexed, so the rabbi explains, “If he is asking to use milk instead of wine, he must not be able to afford wine.  If he can’t afford wine, then how can he afford the rest of the meal?”

This was Jethro’s meaning when he said, “and these people as well.”  An exhausted Moses might go through the motions of adjudicating disputes, but at a certain point he would be hearing without listening.  He would begin thinking of the Israelites, not by their names, but as, “the third case of moldy manna after lunchtime,” or “the last blemished cow argument before dark.”  Sound familiar, healers?

Jethro’s solution is for Moses to delegate, to get “capable men who fear God, trustworthy men who spurn ill-gotten gain. Set these over them as chiefs of thousands, hundreds, fifties, and tens, and let them judge the people at all times.”  Only the most difficult cases would come before Moses himself.  Call it, “Dr. Moses opens a resident clinic,” or “Dr. Moses hires a physician assistant.”

More staff isn’t always the answer; sometimes less work, specifically less busy work, is the answer.  In later generations, Jewish community religious leaders could rely on the fact that they weren’t the only ones who knew the law, because the community had invested in people becoming learned.  The easy questions, they knew the answers or could look up themselves.  Only the hard ones required the rabbi (“Four cups of prune juice?  Mottel, maybe you shouldn’t worry about the wine and eat a little less matzah at seder.”).  Likewise, a healer works less hard when the people they look after are also looking after their own well-being – and when the community does so as well.

Whatever the strategy, something clearly has to give to avoid exhausting the healers.  Take emergency medicine as one example, a career that averages only 7 years before burnout, only about twice the average career of an NFL football player.  Some of that comes from what one of my colleagues lamented on Twitter as “trying to be a therapist, social worker, and primary care doc while simultaneously running my ED.”  The specific structure is not the goal, something that has been forgotten as we create EMRs in service of the billing structure, and then try to engineer workflows in service of the EMR.  The goal is healing unique individual human beings.

The tricky thing is that people are infinitely diverse; the Mishna teaches that a human can stamp a million coins from one mold and they will be identical, but when God stamps a million human beings from one mold, namely God’s own image, they are all unique.[ii]  But there is only one healer, only one Moses, only one you.  You owe it to each of these unique individuals to be uniquely, but consistently, the same you for each of them, at your best.  You do the same thing, in the same way, every time, in order to be prepared for every situation to be different.  Will this be the visit where you diagnose a cancer?  Learn of a rape?  Report child abuse?  If you can’t be consistent, will this be the day that you skip the lymph node exam, or forget to screen for trauma, or don’t notice the bruises, and fail to catch those catastrophic things?

The biggest problem for the healers is that it seems like we are often like Moses with no Jethro.  The “solutions” offered for making our work-life balance better, or for improving our mindfulness, are turned back on us.  Work on wellness.  Engage in self-care.  Fight burnout.  Fix the problem yourself.

We need a Jethro.  I spend more and more time talking to students about how to be “Healers Who Listen,” but they will need someone to help them create a space where they can do that or they will “surely wear themselves out.”  The people in administration, in health services delivery and in health IT need to become “Healers Who Listen” by proxy as well.  Want to claim to be “patient-centered?”  Then remember that Jethro isn’t only worried about Moses burning out, but of the harm he will do to the people if he does.  Put value back on the time a healer spends with someone, stop incentivizing prescriptions over perception, cutting over conversation.

There, I’ve said my piece.  Now if you’ll excuse me, I’ve got to be up at dawn…

[i] Exodus 18:14, 18:17-18

[ii] Mishna Sanhedrin 4:5

Dr. Jonathan Weinkle

Dr. Jonathan Weinkle is an experienced primary care physician seeking to fix our broken healthcare system by returning the focus to the relationship between human beings. His new book, Healing People, Not Patients, gathers together ancient wisdom, medical science, and the experiences of one doctor to draw a portrait of a partnership—a medical covenant—not just between doctor and patient, but also including receptionist, nurse, transporter, and radiology technician.

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