Seemingly everyone in my circle has been reading, and rereading year after year, the excellent book by the late Rabbi Alan Lew, This Is Real, and You Are Totally Unprepared. Not just unprepared for a speech or an exam, not just “appling” (Rabbi Lew’s chosen word for freezing in a moment of decision) over what to make for dinner when you forgot to shop, but unprepared for the pivotal, life-and-death, soul-searching, fate-in-the-balance moment of judgment and redemption that is the “awe-filled days” of Rosh Hashanah and Yom Kippur.
His proposed antidote for being unprepared is to put these days at the center of a dramatic narrative between an individual and Hashem beginning with the collapse of the Temple walls on Tisha B’Av and ends with the construction of new, rickety walls and a roof with holes in it on Sukkot. The drama spans ten weeks, nearly 20% of the Jewish year, yet Lew acknowledges that even those who act out the drama from curtain to curtain are unprepared.
Only last year, on my third pass through the book, did I realize why. My teachers of medicine often said that when we share a life-threatening diagnosis with a patient, they hear everything up until the word, “cancer,” and then they hear nothing at all. The walls come tumbling down; the day of diagnosis is their personal Tisha B’Av, the day they were exiled from their healthy body not knowing if they could ever return.
They often receive that news from a stranger, a surgeon or an oncologist they have only just met, if ever. They may learn their fate in a vacuum, in a sterile hospital room without the support of family or trusted friends. They step into calamity unprepared and unmoored. What’s worse, the people who are supposed to care for them in that moment are unprepared. Not technically unprepared, God forbid; their diagnostic skills and knowledge of treatment algorithms are as advanced as any in the history of humanity. I mean emotionally unprepared, lacking the words and the empathy that can provide them with an anchor.
How do you prepare for Tisha B’Av?
I don’t think for a moment that Alan Lew failed to consider this question. While This Is Real doesn’t address it, Lew was a teacher of meditation who practiced both Jewish prayer and meditation daily and wrote other books inviting people into that practice. That other component of his work points toward an answer to my question: we prepare for calamity every day, moment-to-moment, not through high drama but through the quiet interaction of daily connections with Hashem, building relationships when the stakes aren’t so monumental. It is in these spaces where we build the necessary trust, intimacy, and familiarity, those qualities we will need in the larger moments.
I spend most of my professional life in the other 80% of the year, as it were, in the lower-stakes moments meant to prevent, or at least postpone, the higher stakes moments. I pride myself on knowing my patients well, on knowing their narratives, both the dramatic moments and the mundane details. I pepper my morning huddles with my staff and students with little anecdotes to keep everyone focused on the person (or at least keep everyone alert) even as we create a checklist of vaccines to draw up, labs to collect and referrals to schedule.
But it’s just a party trick. In truth, I don’t know my patients nearly well enough. I have my moments, like the time last summer when I was speaking with a recently married young man at some length about the joy and struggles of the first year of marriage, older dude to younger dude, and about how he could work through the hard parts. But those moments aren’t enough to cover the far more numerous inadequacies.
A new person looking to “establish care” with me (who the hell decided that was the agreed-upon term for starting a relationship with a new doctor?) might wait 3-6 months for an appointment. That’s nearly half a year before they can even begin preparing, before they can hope to acquire for themselves that elusive person who we tell everyone is their best hedge against those awful, dramatic moments – a good family doctor.i
Even a patient who already knows me and is sitting in front of me might wait four weeks to come back when they really need to see me in one; if they call out of the blue and ask to come in it will be eight. When they do come in, they get me for 30 minutes, longer than the standard 15-20 minutes that most people get with their PCP but still not long enough. In the most ideal circumstances, I might spend 3 hours a year with a person – and anyone who sees me that often is already having some drama.
So perhaps it’s no surprise that I “apple” when one of those three hours involves a life-and-death moment. We’ve barely begun a “real” relationship where the other person can trust me enough to share their true fears or be confident enough in my abilities to make critical decisions for them. It takes years to achieve that. I am blessed to have patient relationships that have lasted that long, which means I am also cursed with feeling deep sorrow when those inevitable moments we are preparing for arrive. A year ago, I arranged an in-home citizenship interview and naturalization ceremony for a man who was dying of cancer. I knew I would never see him in person again, but the relationship I had with him gave his family the peace of mind to know I would arrange things for him, and the ability to hear me tell them, “Your father is dying.”
But even that relationship didn’t stop that same man from receiving his initial cancer diagnosis from a stranger. It didn’t prevent the communication breakdowns that meant I didn’t learn of the diagnosis for a month afterward. In a world where I can know what’s in someone’s breakfast smoothie before they finish drinking it, even if I’ve never met them, not knowing that a person I’ve cared for over five years has cancer for more than a month is incomprehensible.
Building relationships and establishing rich communication is tedious, slow, and sure as hell not exciting. Drama gets our attention, whether in medicine, journalism, or even religion. Newspapers, then networks, and now cable and internet news sites have always preached that “if it bleeds, it leads.” Good news ends up below the fold, on the inside pages, or in the last five minutes of the broadcast.
Synagogue pews are full on Yom Kippur for the “awe-inspiring and threatening” holiest day of the year. They dwindle on a regular Shabbat, still more on a weekday holiday, and below the red line for a daily minyan (especially at 9 pm in the summertime). Christians have the same issue when the pageantry of Easter or Christmas gives way to “Ordinary Time.”
Medicine boasts its “celebrity doctors,” but they are people like Michael DeBakey, the heart transplant pioneer, or Ben Carson, the pediatric neurosurgeon whose political career ran with less than surgical precision. The mark of a famous physician is doing something “they said couldn’t be done,” saving lives given up for lost. We are awash in medical TV dramas and films; nearly all are set in emergency rooms and operating theaters (or, let’s face it, bedrooms, focused on the tension and lurid details of the characters’ personal lives). It’s no accident that Shonda Rhymes Private Practice, a spinoff of the outlandish surgical drama Grey’s Anatomy, is the only primary-care-based show I can name. The show was pure Hollywood fantasy, with outrageous, and frequently unethical, high-stakes story lines crammed into a show supposedly chronicling the lives of doctors who check growth charts, do Pap smears, and adjust blood pressure medications for a living.
Except that’s not what we really do. That’s just what shows up in the quality metrics and on our billing sheets. The real work happens in between, when the child we’re weighing tells us what they dream of doing when they grow up. It happens when the person getting dressed mumbles that they’re thinking of leaving an abusive relationship. And it happens when we recommend yet another increase in the blood pressure medication to someone who responds by joking that if their boss fires them because they’re forgetting things at work, no amount of medicine will keep their blood pressure down.
These are tender moments, and they are the moments I love most about the job. And they are too rare. With fewer and fewer of us trying to do more and more for larger and larger panels of patients, we are out of the room before these conversations can happen. The 2023 labor market is such that no one stays put in a job for too long, so depending on longevity and familiarity is a pipe dream – and in medicine, which is increasingly being carved up by private equity, everyone from receptionist to medical director is no more than a cog in the machinery, easily replaced by management, or so fed up with the work that they simply leave. No one in their right mind could expect this milieu to produce people who are prepared for a Tisha B’Av-level disaster. And it doesn’t; when someone suffers an actual tragedy in a medical establishment, our responses can often make them feel as if it’s their fault, or at the very least like they’re inconveniencing others by feeling their feelings. We in a position to help, or who should be in a position to help feel as though there are no words.
Except, as the novelist Dara Horn wrote in her book People Love Dead Jews, “…There are words for this, entire books full of words.” There are words of comfort, words of sorrow, words of anger, not just for communal tragedy but for individual horrors as well. There is a protocol of behavior designed to move from shock to grief to grim determination and eventually back to wholeness. What is lacking is not the words, but the familiarity with them, the intimate knowledge of both the script and of the audience, that allows us not only to respond to that calamity, but for our response to be genuine, meaningful, and welcome.
There are words in medicine, too. Every spring I teach my undergraduate students, most of whom will someday be doctors, PAs, or nurses, about communication mnemonics like “NURSE,” “SPIKES,” and “SOLER,”ii designed to help even the most awkward, uncomfortable health professional find those words when they need them most. Around the same time of year, I sit with my PA students and workshop encounters from their clinical training when they ran headlong into calamity, to help they grow in their ability to be more present, more effective, the next time it happens. And each fall I run an entire semester class on building sacred healing relationships.
I’m an anomaly, though. There isn’t time in the day or room in the curriculum for this material in most places, and certainly not where it matters most: in the training for the people in the front line of care, like nursing assistants, home health aides, and front-office staff. Like prayer or meditation, like doing small deeds of kindness, preparing our words and our hearts for catastrophe can’t be a “special topic” or an elective class. It needs to be an everyday discipline, something we check ourselves on each night before bed and plan out each morning before the day begins in earnest.
We need practice because without it we add to the trauma of the diagnosis instead of mitigating it. It’s true that part of the theology of Tisha B’Av is essentially victim-blaming, explaining the calamity as a punishment for our sins. Yet anyone who has attended a Tisha B’Av service will note that we only do that with the most ancient of the calamities, the destruction of the two Temples 2,000 and 2,600 years ago. The more recent tragedies of the Crusades, the expulsion from Spain, and the Shoah are remembered only as that, tragedies, and their victims as martyrs and innocents.
It’s an example of a lesson medical professionals need. Our patients may, indeed, have contributed to their illnesses, through casual sex, smoking cigarettes, or refusing to get vaccinated. But the moment of diagnosis is not the time to chastise or rebuke. With the distance of time, they may be able to learn and make constructive change. But as the tradition teaches, we cannot comfort the mourner when his dead still lies before him. Or, as the more contemporary saying goes, “Too soon?”
We also need practice because without it we rush to ignore the trauma of the diagnosis and try to mitigate it even before we’ve finished our sentence. Without even a breath, we move from a life-threatening diagnosis to rattling off the potential treatments and examples of miracles we have personally witnessed. As I wrote in last year’s Tisha B’Av post, “Sit With It,” there is comfort in the Tisha B’Av liturgy and ritual, but only after we have dwelt in the grief. Only on the following Shabbat do we get to read from Isaiah chapter 40, “Comfort, comfort, my people.”
We will never be totally prepared. But something needs to change about how woefully unprepared we are, not just for the reckoning, but for these disastrous moments that expose our vulnerability. We need to practice. We need to prepare. We need to remember that there are words, and it is our sacred obligation to know those words and how and when to use them.