Password to a Whole World

I said a strange goodbye last week.  After three years, thanks to a computer system “migration,” I had to part ways with… a password.

Most of my passwords these days are ones that Google randomly generates for me, ones I couldn’t remember if I tried.  But this was one I created myself, one that, thanks to multi-factor authentication protocols, I wasn’t required to change every 90 days.  And it was one that, if I’m being honest, was too tangentially related to the actual words in the phrase for anyone but me to land on.

With several letters, numbers, and symbols altered, the password was ‘Al Shelosha Devarim, the beginning of Mishnah Avot 1:2, which in its entirety reads, ‘Al shelosha devarim ha’olam ‘omed – ‘al haTorah, v’al ha’avodah, v’al gemilut hasadim. “The world (‘olam) stands on three things: on Torah, on service, and on deeds of lovingkindness.”

It wouldn’t have occurred to me to write a goodbye letter to a password, even this one, except that twice in the past couple of months, I spent Shabbat morning at Congregation Ohev Shalom of Bucks County, near my mother-in-law’s house.  The service was in their smaller chapel, the product of a merger with another congregation called Adath Tikvah, where my passphrase is mounted in beautiful, painted, wooden letters around the bulkhead above the ark.  During the quiet moments of the service, it got me to thinking about why, three years ago, I had chosen to make this phrase the first thing that I had to remember every time I started my clinic.

A different Mishnah, Sanhedrin 4:5, teaches that God created a single human being first to teach several lessons.  One of those lessons is kol ha’m’kayem nefesh ahat … k’ilu kiyem ‘olam male.  “Everyone who sustains (literally, causes to exist, or stands up) one life . . . as if they sustained the entire ‘olam, the whole world.”

Every fifteen to thirty minutes, every time I’m in clinic, I open and close a door, and I am in the presence of an entire world.  Each person I see, each life entrusted to my care, is a whole world, and it is my responsibility to sustain that world.  And according to Shimon HaTzadik, Simon the Just, a contemporary of Aristotle and Alexander the Great, there are three things I should do to make sure that happens.  What, exactly, are these three things?

The simple meaning at the time Shimon HaTzadik lived was study of the Torah, the Temple sacrificial service, and deeds of kindness as spelled out elsewhere in the Mishnah.[1]  The 20^th century American rabbi Jacob Neusner interpreted it more broadly: learning wisdom, making sacrifices by giving something up, and doing acts of grace and kindness toward others.  For Neusner, the problem, whether in medicine or any other part of life is that “People tend to do what they must, rather than what they should.”  People follow rules, but don’t understand them, and take selfishly rather than giving of themselves.[2]

Neusner’s contemporary, Rabbi Dr. Abraham Twerski, was both a rabbinic scholar and a great physician, one of the leading voices in the medical treatment of addictive disorders – and, most dear to me, a Pittsburgher.  One of his most famous stories (I can’t cite it in the footnotes, because I heard him tell it to a class I attended) concerns going to a well-known spa somewhere in the southern US for a special sauna treatment.  The treatment was meant to last an hour.  He felt thoroughly relaxed very quickly, and after a bit decided it must be time to get out.  He called the attendant, who informed him that only 10 minutes had passed.

For Twerski, the pleasure of the spa would fall under the category of the ‘Olam ‘Over, the transitory world.  In his commentary on this Mishnah, he observes that the opposite of the ‘Olam ‘Over is, just like in the text, ‘Olam ‘Omed, meaning the enduring world.  He quotes a teaching from the Maggid of Vilna, who likened our lives to binary code – all ones and zeroes.  A long string of zeroes is still zero – and purely physical pleasure basically amounts to nothing.  But a single one, placed at the front of the string, makes a very large, significant number indeed.  When the physical experience of being in the world is imbued with meaning through wisdom, self-sacrifice, or kindness, a zero flips to one.[3]

Changing those zeroes to ones was so important that commentators throughout the ages interpreted this statement to mean that Hashem created the world specifically so that human beings could engage in these three activities of study, service, and kind deeds.  The 19^th century rabbi Marcus Lehmann points to a rabbinic legend that the angels tried to convince God not to create human beings, but the Angel of Love won the day by telling Hashem that humans would use their existence to do deeds of love.  But, says Lehmann, these deeds are not innately part of human nature.  Rather, the three things come in the order in which they appear in a person’s life: first study, in which our children engage from a very early age; then service, when they begin to take on responsibilities for earning a living and supporting their families, as well as religious obligations; and finally kindness, which they take up once they see their basic existence is assured and they have the ability to use both their bodies and their wealth to serve others.[4]

So, where does all of this leave me, the doctor who decided to unlock his computer with this ancient maxim?

Medicine has had its share of golden ages – and its dark periods.  In every case, when things were at their best, like medieval Islam, or the long traditions of China and India, or late 20^th century America, it was a time where knowledge – careful, systematic study of the workings of the human body – ruled the practice of the art.  Great healers study the books at the foundation of their craft – and simultaneously attend closely to the people they are trying to heal, acquiring new knowledge, and refining the old, with each encounter.

Twerski, sounding as much like his doctor self as his rabbi self, cautions that the Mishnah doesn’t just say “Torah,” but “the Torah,” meaning that not just any knowledge will do.  In an age of misinformation, self-diagnosis, and quackery (okay, that’s kind of every age), it’s important to remember that knowledge carefully studied, for the purpose of becoming wise and being a better healer is the goal.  Knowledge gathered sloppily, used to deceive, or harnessed for the purpose of self-enrichment is not what we’re after.[5]

Service clearly doesn’t mean sacrificing animals anymore, but there is a lot of sacrifice in medicine.  Long minutes of tension in critical situation, long days and nights of call and drudging work during training, and long years of delayed entry into independent practice require a personal price – sometimes too great a price, forming a barrier to entry for many who cannot afford the luxury of waiting to earn a living while toiling at below minimum wage for the privilege of being a physician-in-training, and straining the Lifeworlds of many of those who do enter the field to the breaking point.  A story circulated when I was interviewing for residency that a certain surgery training program boasted a 110% divorce rate among its trainees in a previous cohort.  When questioned, they explained that of 10 trainees, all had been divorced during the program – one of whom then remarried and was divorced from that spouse by the time they finished.

Yet failure to serve, at some personal cost, is incompatible with medicine.  Arguing on behalf of a patient with an intransigent insurance company or reluctant specialist, waking in the middle of the night to take a call that ends up being the initial clue that a six-year-old patient has diabetes, or staying late in clinic with a family who has just learned their loved one’s cancer is no longer treatable are all inseparable parts of the profession.

But, as Lehmann suggests, the mature physician must finally learn kindness.  The prototypical doctor of the technological Golden Age of the late 20^th century worked 100 hours a week, did amazing technical feats in the operating room or intellectual feats in the diagnostic process, but towered over their patients with an imperious attitude at the hospital bedside.  Patients left their presence physically restored, but confused, overwhelmed, and often hurt by what transpired in those interactions.  It was almost as if, to them, the patients were ‘olamim ‘ovrim, passing worlds that disappeared from consciousness as soon as they left the clinic or the hospital.

But our patients are not ‘olamim ‘ovrim, but ‘olamim ‘omdim, enduring worlds.  We make a covenant with them to heal not just their bodies, which are transient, but their souls.  They stay with us long after they are physically gone, whether from the clinic or from the world – both our joys and our tragedies with them.  And it is the kindness that we show to one another that binds us to them in that way.  Over the past few years, I’ve written about many specific types of kindness that we can show in our healing work, whether it is accompanying a person on their way as they take leave of us or being careful to choose words of kindness instead of words of hurt when speaking to someone.[6]

What can be frustrating is that the 21^st century system doesn’t seem to stand on any of these things, but rather on the efficiency and the profitability and on deeds of convenience.  Our electronic medical records, rules, algorithms and boilerplate language serve mostly to minimize friction, render healing professionals as replaceable parts in the machine, and flatten out the pesky individuality that makes a patient a person.  Which is, in the end, why I chose this phrase as the key that unlocked the door to my days as a doctor for the last three years.

We may have changed the locks, but I think you’ll find that the key still works – for all of us – once you get through the door and enter that enduring world of healing.

[1] Listen to the next episode of my Healing People, Not Patients podcast for one beautiful example.

[2] Neusner, Jacob.  Torah from Our Sages: Pirke Avot.  Dallas: Rossel Books, 1984, p. 26.

[3] Twerski, Rabbi Abraham J.  Visions of the Fathers.  Brooklyn: Shaar Press, 1999, p. 17.

[4] Lehmann, R. Marcus and R. Eliezer Liepman Philip Prins.  The Lehmann-Prins Pirkei Avoth.  C.H. Moore, tr.  Jerusalem: Feldheim, 1992, pp. 6-7.

[5] Twerski, p. 16.

[6] For one specific example, treating the patient encounter in the same way as one visits the sick, listen to the upcoming August 4 episode of my podcast Healing People, Not Patients (ep. 19) at https://healerswholisten.com/podcast/.