EP. 59: A SPACE FOR PURPOSEFUL REST

Apr 26

WITH JUDITH SHULEVITZ

A writer and literary critic shares what we can all learn about purposeful rest and reflection from the tradition of the Sabbath.

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Episode Summary

In the Judeo-Christian tradition, the Sabbath is a day of rest during the week. Our guest in this episode, Judith Shulevitz, is a journalist and literary critic who has thought deeply about what the secular world can learn about meaningful rest from the practice of the Sabbath. In her book The Sabbath World: Glimpses of a Different Order of Time, she explores how, despite our culture of workaholism, we can still discover the restorative joy of rest, reflection, and family. Shulevitz is also a regular contributor to the New York Times and the Atlantic, and is the chief science writer of the New Republic. Over the course of our conversation, we discuss the origins of the Sabbath, the ideals this tradition can bring back for the individual and community, and how clinicians can create space for purposeful rest amid their busy lives.

Judith Shulevitz is an American journalist, editor and culture critic. She has been a columnist for Slate, The New York Times Book Review, and The New Republic. She is a contributing writer for The Atlantic.
In this episode, you will hear about:
• What drew Shulevitz towards re-engaging with her Jewish faith as an adult - 2:50
• What observing the Sabbath looks like in a traditional Jewish household - 5:20
• An exploration of the idea of a “secular Sabbath” and what it could mean for the modern world - 10:33
• The relentless culture of medical residency training and the factors contributing to it - 13:00
• How medical training affects physicians’ sense of community - 36:37
• Shulevitz’ advice to those with very busy schedules on how to make space for purposeful rest in their lives - 38:52
• Reflections on the need for physicians to process the extremes of emotion and suffering they encounter - 47:36
• Why it is critical to be present in the real world during times of rest - 50:45
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Tyler Johnson: [00:01:03] I wanted to start actually by giving a little bit of a point of view from Henry and I. You know, we're entering the second year of the podcast. We're about exactly there in terms of recording. By the time you all hear this will be a little bit into the second year. But as we're doing this, we're trying to make a little bit of a purposeful pivot in the following way: Almost everybody that we have talked to in the first year of the podcast, their connection to health care has been pretty obvious, right? They most of them were doctors, some of them were nurses or other health care practitioners, and then a few people who were health care adjacent or even patients and their family members. As we move into the second year, we're hoping to also we will continue to do that, of course, But we're hoping to also speak to some people whose connection to the health care world is maybe not as obvious, but who we think have ideas that have the potential for being really powerful and even transformative for health care practitioners, as we think about how to find that connection to the deeper meaning that brought us into medicine.
Tyler Johnson: [00:02:00] And so with that in mind, we are really grateful today to have on the podcast with us Judith Shulevitz. I first heard her myself listening to a podcast, Ezra Klein, who records a podcast for The New York Times that is this general interest podcast where he talks to all kinds of people about all kinds of things. He had her on the show, oh, maybe 2 or 3 months ago. I was really captivated by her ideas. She is as as I'll let her explain in a moment an expert and has written a book about the idea of the Sabbath. And that's the reason that we invited her on the podcast. You may be kind of scratching your chins wondering what in the world this has to do with becoming an internist or whatever it is that you're training to be. But we're hoping that we can draw that idea out in the podcast, and that's what we're hoping to talk about today. So Judith, thank you so much for joining with us in conversation.
Judith Shulevitz: [00:02:49] Thank you for having me.
Tyler Johnson: [00:02:50] Could you start by just telling us a little bit about yourself? What's your background? What do you do and how did you get to where you are today?
Judith Shulevitz: [00:02:57] So I'm actually a literary critic. I'm a book critic and general contributor to The Atlantic magazine and to The New York Times. And I've been an editor, but most of all. I have been on a kind of Jewish journey and went from. Being raised in a quasi religious household to not setting foot in a synagogue for years to beginning to grasp an absence in my life. I began to feel kind of accidentally when somebody told me I needed to go to synagogue because I wanted to go to church. I wound up becoming part of a what we call a Shabbos community, which was my point of entry back into Judaism. It was while explaining this idea to my then super assimilated but Jewish husband who never thought of it in any but negative terms that this was this collective pause, not just a break in the week, but a break in the week that happened for everybody at the same time, allowing for community. That I saw because he's one of those people who makes everything you say sound more interesting than you realize it is, that we together saw that this was an idea vanishing from our world, except in, you know, Orthodox communities and Seventh Day Adventist communities. And that it was really one of the good ideas of Western civilization and should be presented as such. In other words, not just a history of the Jewish Sabbath, also a history of the Christian Sabbath -because in terms of absolute numbers, more Christians than Jews have kept the Sabbath- and mine it for ideas about the ideal organization of society, not just the religious organization of society. When you said the idea of the Sabbath, I do want to stress that because I thought of it as presenting a history, presenting a sort of account of my own personal experience with the Sabbath, but also saying this is a social idea, this is a sociological construct of time and we can extract lessons from it that can be used not just by the religious but in general.
Tyler Johnson: [00:05:20] So before we get to those generalized applications of the idea, let's back up for a moment and ask this question What does the Sabbath look like? We're not talking yet about any of the sort of larger ideas, but just on a day to day what happens on Saturday? Like, what would that be like if you're growing up in an observant Jewish household?
Judith Shulevitz: [00:05:41] So I want to distinguish myself from an observant household. I said quasi-observant, because in fact, you know, it was a kind of mixed marriage. My parents was a kind of mixed marriage in the sense that my mother was herself moving in the direction of religion and wound up becoming a rabbi. My father couldn't have been less interested. So there was always this tension in our household between what my mother considered the ideal disposition of time on a Saturday and what he considered the ideal disposition of time. However, that said, I have spent time with people for whom this kind of internal division within the family is not the case. And so I can talk about what it's like at its best. When you're immersed in a Sabbath community, you keep the Sabbath the way Jews who follow what's called halakha or Jewish law keep the Sabbath. Again, I would say an idealized Sabbath. There's a very small number, comparatively speaking, of people in this country who keep it that way. But what I would say is I want to stress, first of all, that there are positive commandments and negative commandments, positive traditions. I would say things you do and things you don't do, I would highlight to begin with the tradition of a Sabbath dinner, which involves a lot of preparation beforehand because you're not supposed to do certain kinds of cooking on the Sabbath family togetherness. You know, it is a tradition to invite people over or to be a guest. You light the candles, you say some prayers, often you sing.
Judith Shulevitz: [00:07:23] There are Shabbos songs, there will be copious food. I'm always struck by how there's like 2 or 3 entrees and vast numbers of appetizers to go with the challah, which is a bread that is braided bread, which we've all seen that is specific in the Jewish tradition to the Sabbath and holidays. Traditionally you save up the choice bits of food, kinds of food and serve it on the Sabbath. So it's a real banquet. So it's a it's a it's a wonderful tradition. So that's the Friday night. Saturday, If you were talking about an Orthodox family, traditionally a man will go to the synagogue. Women can or can not go. It's their choice. If you like prayer, this is a great thing. If you don't, probably you wouldn't go or you don't like it. There will be study afterwards and there study in the service every Saturday you read from the Torah or the five books of Moses and then often study in the afternoon there will be a big Shabbat lunch again, a very communal meal prepared in advance, often something some kind of stew that can be kept in an oven on low heat as a main course. There's a tradition after the meal of sleeping, resting, and it ends with something called havdala, which is a literally means separation. So it's a ceremony after the Sabbath has ended and you light a candle and you say some prayers and drink some wine and usher yourself back into non-holy time, regular time, the the workweek.
Judith Shulevitz: [00:09:00] So those are the positive things. The negative things would be things you don't touch things you don't you don't turn on lights. You don't use technology. You don't drive again. This is orthodox, in the conservative movement, you can drive. You certainly don't shop. You don't handle money. Depending on how observant you are, you will put away anything that will tempt you to do kinds of forbidden work. Like my favorite one is you must get rid of all your scissors because you're not supposed to cut. You know, So those are the negative prohibitions. They have the effect often of, for example, not driving. You might not want to walk too far. So it's very home-bound. And it and so it's Judaism is a very home centered, family centered religion. It keeps you home. It keeps you with your family. Hopefully you have one or your community. It enforces this togetherness that I think is part of the essence of it. You know, there's there's all kinds of rules like that which, again, are designed to not only prevent you from working and prevent you from traveling too far, but the sort of theological underpinning is this idea that you do not use the world, the material world in an instrumental way. So in a weird sort of way, you know, you let the world rest. You let yourself rest and you stop trying to master the world to produce things from it, which I think is a it's a kind of you could think of it as a mindfulness practice.
Henry Bair: [00:10:33] So you've told us what Sabbath means on a theological level, but your book, The Sabbath World, actually proposes a sort of secular Sabbath that you believe we as a society should explore and adopt. Can you tell us what some of the applications of Sabbath to a secular modern world would look like?
Judith Shulevitz: [00:10:52] So for society more broadly, I would say that the most immediately useful application of the idea would be to stop using technology. I think that has become a kind of urgent need because in a way we tend to forget when we're on our phones and on our computers doing work that there is another mode of being in the world and it's super hard to turn off your devices. I mean, you have to do a lot of preparation in a weird sort of way. You have to make sure that your time is filled in a positive way. You have to make sure that you don't urgently have to turn some piece of work in. You have to make sure that you've made plans in advance to meet at a certain place so that you don't have to turn your phone on. So these are these are very difficult things. But I think as the pace of life quickens, as expectations of productivity increase, as boundaries of work soften and more of us work at home on our own schedule, which I think for many means they never really feel that they are allowed to stop. Even though you make your own schedule, I think you're always feeling like, Oh, you know, I need to get this done. I think that becomes more important. And I think another piece of this is just the idea itself of boundaries that time has boundaries that you need to set boundaries. I think this is tremendously important and I think it's something that is in danger of disappearing as we move more and more away from a kind of collective time, let's call it 9 to 5 time, you know, that's a little arbitrary. There's other ways of describing it. But toward a more personalized idea of the relationship between work and leisure, I think that's in a way the lesson that can be kind of extracted from the religious Sabbath and used to think about the organization of our society today.
Tyler Johnson: [00:12:59] I remember reading this really striking essay by a Christian author a number of years ago. He was giving a like a sermon or something. But the point was that he had been called to this relatively rural town to give some kind of a religious message. And this was probably now 40 or 50 years ago. So probably, I'm going to guess in the 70s. But by and large, all of the members of this rural community belonged mostly to some Christian religion and were very, very serious about keeping the Sabbath. And so he describes that the place where he was going was on a sort of a hillside that was on the far side of this town, and the town was located in a valley. So he kind of crests, crests the hill to come into the valley and then goes through the valley and then comes out on the other side. And this was a largely agrarian community. So most of the people there were farm workers. And as he started to drive through, you know, the fields and whatever, he noticed that all of the tractors and other farm equipment were turned off. Nobody was working in the fields because it was the Sabbath. And so then he finally gets to the far side of the valley where he's going to be offering his sermon or whatever, and has gone through the entire valley and has not seen a single person working or a single store that was open. And so then as he gets to the far side of the valley and looks back from the far hillside, he has this, I don't know, waking dream or an impression, whatever you want to call it, that it's not just that everybody in the valley is resting, but that the valley itself is being allowed to sort of take a breath, to relax in between the the days when it was being put to such hard use and such hard work and even the animals and whatever are allowed to rest on the Sabbath.
Tyler Johnson: [00:14:46] I think that there is this genuinely penetrating and powerful idea about allowing a space for communal rest, right. Where everybody knows that everybody around them is dedicated to observing this break in space time and allowing everyone around them to to celebrate this sort of deep breath, communal, deep breath, I think is is really beautiful. Having said all of that, this gets really, really tricky for any doctors and especially for doctors in training. Right. Because, Judith, we're inviting you here as a sort of a medical outsider to try to help us think out loud about what these ideas can mean for us. I think it's just important to give a little bit of, you know, first person medical background. And I'll allow Henry to add to this if he wants. But, you know, I remember actually when I was getting ready to go into the the hardest year of medical school, which is the year when you do what are called your core rotations, which is where you you spend two months doing obstetrics and two months pediatrics and two months internal medicine and whatever as a way to allow you to sort of experience all the major fields and know what you want to do.
Tyler Johnson: [00:16:00] A couple of months before that, we got a letter from our Dean of students, which I still remember, not quite verbatim, but pretty close that basically said, Dear Tyler, this letter is to inform you that in January you will start your year of core rotations. We just want to inform you that during that time you will be expected in the hospital at least six days a week. And on the days that you are working, you may work as many as 14 to 16 hours a day. You will not have weekends off. You will not have holidays off. You will not be able to take vacations except for one planned two week vacation during the summer. Please inform your family and friends that you will not be available for social events such as weddings and weddings and funerals. And any absences that you take from your acquired curriculum will be noted as unexcused absences and reflected on your Dean's letter when you apply for residency. Right. So that was kind of the MO. And you know, that that letter was unusual in the sense that it was we're usually not quite that explicit in articulating it, but that's kind of the ethos really throughout your medical training, right? The expectation, the reason residency is called residency is because originally residents literally lived in the hospital.
Tyler Johnson: [00:17:17] They were residents there. Right. And so the expectation is that your life gets kind of flipped upside down such that it's almost as if the hospital becomes your home and the expectation is that your default position is going to be to always be in the hospital. And anything that anything else that you want to have happening in your life, it has to function around that. And to that point, I remember you're aware of the work hour restrictions, so there have been multiple iterations of work hour restrictions that have been put into place for residents and fellows over the last, let's call them, 20 years. That was in response originally actually to a New York Times article that described in detail how residents, you know, virtually never rested before. These, you know, the restrictions. A lot of people laugh at that term because it's things like you can only, quote unquote, work 80 hours a week or you can only, quote unquote, work 30 hours at a shift or whatever. But even so, when those restrictions were put in place, there were two of the most prominent program directors of internal medicine programs in the country wrote a letter to the New England Journal of Medicine that in effect, said, We cannot train doctors under these work restrictions. It just it cannot the training cannot happen appropriately. And if these aren't changed, you know, in effect, we will quit because we just can't do this anymore because training is not possible under these, quote unquote, restrictive conditions.
Tyler Johnson: [00:18:44] So all of this is mostly by way of saying to you as an outsider that for residents, Right, there is just almost no respect whatsoever for a boundary between, you know, work life and home life. Because then, of course, the other thing, right, is that even when you go home, your patients are on your mind and often you have to write notes and do other things that you weren't able to do when you were, you know, in the middle of the hurly burly of being in the hospital. So given all of that as context, part of the reason that we invited you on to the podcast is because even though that clearly makes the idea of any sort of observation of a secular or medical or whatever you want to call it, Sabbath, all the more difficult. We would argue that it also makes it all the more important, right? And we are hoping that we can think out loud a little bit given about this question, given those really difficult restrictions and given to culture that is almost, you know, seems almost designed to oppose the idea of a Sabbath, like what principles do you still think that medical trainees in particular and doctors and nurses and nurse practitioners and whatever, but what principles do you think they still could try to draw out of the tradition of the Sabbath to try to make the rest that they do get and the time that they do get more meaningful and more nourishing?
Judith Shulevitz: [00:20:11] Well, here's what I've never understood. What is the point of this kind of insane boot camp mentality? Why would those two, you know, heads of medical schools or whatever they were, have written that letter? What do they think they're accomplishing by putting, you know, their doctors in training through this sort of torture? I've never really understood it. So maybe you can explain the logic.
Tyler Johnson: [00:20:38] Yeah. So I would say that people would fall into sort of two camps there. So you used the term boot camp. It is absolutely the case that if you go through your medical training, you are almost certainly going to encounter someone who uses even verbiage. But but whose attitude is very much like that. Right? So I remember being one time I was working in the ICU, I was at the end of a 30 hour shift and was looking tired on my shift and and my attending physician, my boss sort of saw me yawning or whatever and sort of pounded his fist on the table and said, "you guys know you're all wimps, Right? When I was a resident, we used to work 36 hours, sometimes even 48 hours in a row. And this whole thing about 30 hour shifts is you're all wimps and stop yawning." That was basically the speech that we got, right. So there is a little bit of this kind of, you know, this is how it was for us. And so you need to go through it, too. There is just I think it's important to be candid that there is some of that.
Henry Bair: [00:21:42] That's actually the one we hear in the hospital amongst when I work with residents, that's actually the the single most dominant argument. That we hear is that it's a problem of culture.
Tyler Johnson: [00:21:53] Yeah. Now, just to give full airing to what I think some people would say is the other side. The clearest logical explanation that I have heard is that there is an argument to be made, at least when you're working in the hospital, that there is an a unique benefit to taking care of a patient who has just come into the hospital for the first time for the first 30 plus hours that they're there for the following reason. It usually takes about 8 to 10 hours to do an initial evaluation and sort of decide what do you think is going on? Right? You have to wait for blood tests to get back and a CT scan and evaluation by this doctor and that doctor and whatever. And so it can take about 8 to 10 hours to say, okay, now we have enough information. We think that the diagnosis is X and so therefore we're going to implement treatment Y. So then it usually takes, let's say five, six, seven, eight, nine, ten. It depends on what you're doing, but it takes some number of hours to implement the treatment and to give the treatment time to sort of take effect. Right? You're giving antibiotics and you want to see if they work or you you give them a blood thinner and see if that helps or whatever it is. Then after you have done that, you need time to see what was the effect of your treatment.
Tyler Johnson: [00:23:11] And then if your treatment worked, great. But if it didn't, then sometimes you have to sort of go back to the drawing board and say, okay, well now what if that didn't work? What do we think is going on? Or how do we have to modify things or whatever? And so then you have to take your second pass and then go through and implement another round of treatment. So some people will make the argument that allowing trainees to continuously follow that arc of initial assessment, initial diagnosis, treatment course, view the response to treatment, renegotiate what's going on and then make another another pass at, you know, sort of your treatment course or whatever. The tracing of that arc continuously means that working for 24, 30, 36, whatever it is, hours at a shift is really, really important. Now, obviously, you can poke holes in that and and in large part we have because it's much less common now to work 30 hour shifts than it used to be. But I think that's that's part of it. And then the other thing that people will say is just that you need X number, There's the famous thing about 10,000 hours to become an expert, although I know that's sort of been debunked. Some people think.
Tyler Johnson: [00:24:17] But anyway, there's also the idea that you just need X number of hours to be sufficiently trained to be an attending physician. And so some people will say, well, okay, fine. If you want to not have 30 hour shifts anymore, then whatever. But then residency, for instance, to be an internist instead of being three years, it needs to be five years to make up for the fact that you're shortening the shifts from 30 hours to 16 or what have you. And then of course, the other thing is that there's also a part of this that is just the business of medicine, right? That residents are if we're just being candid about it, cheap labor. And so they get plugged in to fill a lot of the holes at night and on holidays and whatever. And you know, times when a lot of other doctors don't want to work. And it's I mean, I hate to be crass, but it's convenient from administrators perspective to have people who they can have work 30 hour shifts because it covers so much of what the hospital needs done. But I think those two other arguments, the one about just the sheer number of hours and the one about tracing an arc over 30 hours are the ones that if people were trying to defend it, I think that's probably what they would say.
Henry Bair: [00:25:15] Yeah, I think that the point about the maybe it's just this is just the number of hours it takes to train a physician. I think that one is actually one that's pretty obvious because you can use the numbers to to to kind of back up that argument, that proposition. Speaking from my perspective. So I matched into ophthalmology So I'm going to be starting ophthalmology residency this year in the US it's four years of training after graduating from medical school in the UK it's nine years. That's the minimum required. And when I talk to colleagues in the UK like, Why is your residency almost a decade? Why is it more than double my training here? And they said, Well, you work more than double the amount of hours than we do. And it's true. The EU regulations, the work hour restrictions of residents in the EU is 48 hours, which is almost half right. It's a little bit more than half of the work restrictions of the US. So there's that. And then when I look at other residency programs and other countries, other systems that take about the same year. So I come from Taiwan, so I know plenty of residents in ophthalmology in Taiwan. The residency program, the length is about the same as the US, but most of the things that ophthalmology residents learn in the US, like all the procedures, like the retina procedures, the cataract procedures, the glaucoma procedures that you do as a resident is what you do in fellowship in Taiwan. Like those are things that you residents are not trained in, right? So I think that's an argument that is pretty difficult to dismiss, right? I mean, I guess you could say, well, then it comes down to a trade off, right? Would you rather work for fewer number of years but work much harder or do you rather drag it out and then work less per week, but then, you know, potentially double your training time?
Judith Shulevitz: [00:26:57] Well, I would say two things that strike me about residency or core rotation being so boot campy is that one thing is that it seems to be a weeding out process. It's sort of raising the barrier to entry for doctors. So in a weird sort of way, it's a guild mentality being put in place. We're not going to let anybody but you know, the people who survive this test into our guild, which you know. I don't know whether it's really makes sense anymore, but the main thing that bothers me about it is that it's sexist. It is a holdover from a time when there was no biological time clock on your reproduction. There were probably no family duties, even if you were married. And, you know, residency does come later in life than many things. So many people presumably are married, although maybe they're not I don't know what the statistics statistics are in The medical profession about Know rates of marriage while training. Given the division of labor in our society, especially domestic labor. And I would Also add emotional labor and sort of home management Labor, which is part of Domestic labor, It's just sexist. It just discriminates against women. I mean, it's just that simple.
Judith Shulevitz: [00:28:17] So that's one of my main objections to it. A woman who wants to start a family when she's younger rather than older and may have problems getting pregnant just really Can't You know, And you can say, oh, well It's shorter, but, you know, it's it's shorter, but you're really blocked off from from doing much during that time in terms of starting a family and living that kind of life.
Tyler Johnson: [00:28:44] Before you get to your second reason. I do think that it's just important for us to note that there is a- I think the United States is going through a collective grappling right now with what it means to be a medical trainee and the reason that I say this is because for many years the assumption has been that once you sign your name on the dotted line to be a medical trainee, there has just been an an inviolable assumption that that is your first priority. And in effect, you will do whatever the directors of your program say for as long as you are in the program, period. And to your point, for women who are seeking to start a family, that becomes an almost insoluble problem, right? Because like the idea of maternity leave or of being able to have a place to pump breast milk if you've had a baby or, you know, I mean, all of those things have just been not even on the radar, right. Until really the last 5 or 10 years not to even get started on the fact of how much money are you making and what about paternity leave or what about medical leave? Or what about if a family member gets sick or, you know, all of those things? I mean, that's just been it's just been understood that that doesn't even come into the conversation. And it's really only over the past 5 or 10 years that now people are at least starting to ask those questions. And people are starting to say, well, you know, what should this look like? And it is interesting to note that the all of the residents and fellows about a year ago at Stanford voted to unionize and are now in the process of their initial union negotiations. Not certainly exclusively about these things. But but I think that is a sort of a symbol of the fact that these questions are starting to be asked and it's starting to be recognized that residents or fellows, though they are residents or fellows, still need to also remain people, which just honestly has hardly been a consideration up until now.
Judith Shulevitz: [00:30:51] Yeah. I mean, it's it's inhumane. I mean, the EU has a history of being more respectful of boundaries of time in a labor context, you know, and also it's been sabbatarian for longer, for more years into the modern era. So it just it does make sense. To go back to your point about this arc Of a hospital stay and this arc of treatment. You know, in an er of computerization of, you know, the ability to record so many kinds of data and pass it along, it just it makes less and less sense to me. You know, you really can pass information to another person who presumably is has the same training as you and presumably is up to some minimal standard that the hospital imposes and should be trustworthy in terms of making the diagnosis or adjusting the treatment. So it just it really makes less and less sense. I understand it from a pedagogical point of view, but it really doesn't have to last for years. You could say, okay, we're going to take two months and you're going to learn about this arc of treatment, but it just doesn't make sense to to, you know, impose it for such a long period of time, thus preventing, you know, a resident or a trainee from living a life for a really shockingly long time.
Tyler Johnson: [00:32:17] So every semester, basically, I go back to my alma mater to give a lecture called Counting The Cost. There's no medical school there. And so and I know that when I came into medical school, I just had zero idea about any of this. Right. And one of the things that I tell people when I give that lecture, which is precisely about trying to help them understand what they'll be giving up if they go through medical training, is that from that year of core rotations in medical school, on through residency and then fellowship, they will be, in my estimation, lucky if they can honor the priority of what they're doing in the hospital and then their most important relationships, meaning basically spouse and children or significant other and children. That's it. Right. I mean, if you think you're going to have a hobby or if you think you're going to have leisure activities or if you think you're going to exercise regularly or if you think you're going to. I mean, those things almost by necessity are just going to completely go out the window because there's just no, it's just not logistically possible. There are only so many hours in the day. Right. And it and you just at least as it exists right now, you just have to understand that that's the sacrifice that you're making by training for medicine.
Judith Shulevitz: [00:33:32] How do you think this affects doctors social skills? I mean, I wonder You know, part of What we do in our communities In our circles of friends, is learn to listen, learn to Show up for people, learn the values of kindness and cooperation. Now, I mean, that said, of course, you're part of a community within the hospital. But I just wonder, have you ever made that connection?
Tyler Johnson: [00:33:59] Henry, Do you want to take that one? You're sort of more in the middle of it right now than I am.
Henry Bair: [00:34:04] Well, I don't know. I mean, medical school is not easy, but from all the information I can gather, I think that the next four years are going to be significantly tougher. So I don't know how I'll feel about this. I mean, it is different being in medical school. I would say that the transition from like the classrooms to the core rotations, as Tyler described earlier, was a profoundly isolating experience because you like the last time I spent time with my class was the very last day of the pre-clinical years, right? Like, I remember we had like this ice cream social, like one of the senior medical students had like popped by. And then he kind of facetiously said, "Oh, this is the last time you'll see most of these people." And I thought, okay, sure, he's exaggerating. But no, that is that is true because once you're in the hospital, you kind of just get broken up. You split up, you're assigned to the individual wards, individual teams, and then you kind of have your own schedules and you never see your classmates or your friends, really. And finding the time to even grab a meal with them is so difficult. And I can just imagine that's probably going to be even more so the case in residency training. So that's one aspect of it, is that my my personal your personal community, your sense of community is just gone and it's very difficult to reestablish that. The other thing is that the sheer difficulty of the work itself and the long hours involved, I think does wear down your ability to connect with other people. Absolutely. Like I've you often hear statistics about how residents who are married often have like a divorce, a separation rate that is far above the general population of a similar age. Basically. Yeah.
Judith Shulevitz: [00:35:47] I wondered about that. Definitely. Yeah.
Henry Bair: [00:35:49] Yeah. I think the statistics do bear that out. And I think when I when I talk to residents who are in relationships, they do find it so much more difficult to connect with the people who are important for them. And that's partly because you're sleep deprived, you're overworked, you're tired, you are less patient with everyone around you. So that's that's definitely something that that I see. Tyler, do you have anything else to add to that?
Tyler Johnson: [00:36:13] Well, the other thing is that I think, you know, to your point, Judith, I mean, you certainly have a sense of community. And I was really lucky actually, in my residency program in particular, I went to Stanford for internal medicine residency, and actually I think we had a program directorship that was more mindful of this than many are, and mostly just the people who I was co-residents with were really fantastic. So that we did have a sense of community. I mean, I felt sort of in communion with them, although it was the kind of communion that you find in the trenches, so to speak. It's sort of a sad reality that all of the metaphors that come up seem to be militaristic ones. But, you know, it really does sort of feel like being in the foxhole a little bit. Not that I really know what that feels like, but but that's the sort of the image that comes to mind because you're so profoundly isolated from anybody else, but then are in such constant communion with the people who are there with you. Right. That's the thing that seems apropos, not not the trauma of warfare, obviously, but but by the same token, you do become as I said before, it was everything that I could do to honor the, you know, 2 or 3 relationships. Once we had kids that were the that were the most important to me. But everything else, you just have to put your life on hold for however many years you're doing it. It is a profoundly strange thing, something that I think is difficult, honestly, to imagine unless you've been through it.
Judith Shulevitz: [00:37:36] I mean, what you're describing sounds like a cult, right? You you know, you isolate the person, You you sleep deprive them. Right? You you cut them off from their family and friends. They are together all the time. You have a highly, I think, authoritarian structure of control. Right. Of command. It really you just describing a cult.
Henry Bair: [00:38:00] I've never thought of it that way. But I see. I see it.
Judith Shulevitz: [00:38:05] Now. I mean, it's also a way to shape a culture and a mentality. So I suppose that's what people think is important. I mean, we haven't even talked about the error rate, which I know you know, I have no data on and have only read like New York Times articles about it, so I Can't really talk about it. But the we could talk about the emotional error rate. We can talk about being on the receiving end of Treatment from people who are in this state of intense stress and intense pressure. You know, I've always found residents to be kind of compassionate, surprisingly Compassionate, given what their the the pressure they're under. But, you know You also feel like This idea that they have to get to the next thing right away, stop with your questions. You know, I just I wonder sometimes how it Affects the way they interact interpersonally.
Tyler Johnson: [00:38:52] And one thing that I, I just want to put out there is that I'm a pretty devoted member of a religious community myself and which I want to bring up for two reasons. The first one is that I want to say that while I was in my training, that was unquestionably one of my personal and our families lifelines, right? To have a community outside of the hospital to which we knew we belonged and to which we knew we like. We knew that we had a place there was really, really important. And and stepping back into a world where I was able to respect boundaries, defining sacred time and sacred place. And all of the rest of it has been even. I mean, I did that sort of in the meager way that I could while I was in my training. But stepping back into that, since I have left, my training has been in a, you know, in a more sort of wholehearted way has been enormously important. Right. And I and which the reason I bring that up is not so much for my personal story as it is to say that I think what what you're getting at and what I think we need to recognize is that the you know, not everybody obviously, who listens to the podcast is going to be deeply religious or is going to join a faith community where they respect the Sabbath or whatever.
Tyler Johnson: [00:40:20] But but the point is just to say that even if we're talking about the idea of a secular Sabbath, it's just it's almost by definition impossible to really do it right when you're in your training. And I guess that part of what we're saying is that we need to recognize that that is a genuine and deep loss, right? Among the many losses that you incur when you're training. That is a deep one. And I think, you know, Judith, you're being candid about that and things you're saying, and we should be candid about that. I do, though, still want to come back around and pose this question again, Judith, because I think this is what is really important for our listeners, many of whom are right in the thick of this. So let's say you're a resident, you have one day off a week, and on that one day off, you're going to be exhausted because you've been working so much. And. And you're going to have your your time is unbelievably precious, right? Because you've got to do laundry and grocery shopping and be with your family and whatever. But like what Still, even within that widow's mite, so to speak, what practices like what concrete recommendations could you as sort of an expert in the idea of the Sabbath give that might help to make that single day off more meaningful or more nourishing or rejuvenating?
Judith Shulevitz: [00:41:45] Well, just let me quickly say, I don't know why it has to be six days a week, but okay, let's stipulate that it is. Yeah. I mean, I think the lesson I take away from my experience with the Sabbath and would offer up as potentially helpful is take pleasure in things. Create kind of rituals with your family because presumably it is your family that are pleasurable. Don't just do your laundry. Don't just shop. Don't have, "Quality time" with your Kids. This idea that you're going to cram in a couple of hours, all the things that ordinarily would happen organically over the course of a week, quality time. I think as a mother, I have found to be just incredibly oppressive. You know, it just puts all these expectations on time that no kid wants. You know, just. Find a way to create something that will happen regularly so that you actually do it. And I'm very food oriented in my family. My husband is an incredible cook. My children have turned into incredible cooks, even quite young. And so we're very oriented around meals and I think that's a really good one. But maybe there's something else. Maybe you like to go to the park and play baseball or go to the beach or whatever it is that you do. Just make sure it's not just like sheer life maintenance, you know, but that there's pleasure and that it sort of happens regularly every week, if that's possible. Now, you might be talking about sort of a couple in which they're both residents. And then I don't even know how you do that. That just you're never going to have that togetherness, but you still probably want to have something that's. Positive and pleasurable and not pressured. Fine. Then you have to find a way to do the laundry during the week. And or, you know, send it out or whatever it is. And I know you don't have a lot of money, but you're going to have to find a way not to have it just be grim. The productivity of life. But fine.
Henry Bair: [00:43:52] Yeah. And I think it's not even just like I know that the word the the translation of the Hebrew for what to do on the Sabbath is often the word "rest." But I think it's not even just to not do things right. Like to your point, it's actually it's not just to like, refrain from doing stuff. It's not just remembering observing, but it's also honoring and delighting in. So there's like definitely like a celebratory aspect to it, Right? And I think that that cannot be lost here.
Judith Shulevitz: [00:44:21] Yeah, That's the famous Isaiah quote. You know, "let the Sabbath be a delight." That's exactly. Right. So that's that would be my recommendation. And my other recommendation would be join that union. You know, unionize. I mean, we forget that, you know, one of the major demands of unions during the early years of unionization was time, you know, because they worked these insane, you know, work weeks and they wanted a sane workweek. That is a labor issue. It's a really important labor issue. I think that, you know, medical residents understand that and have already taken it up because they live under such extreme temporal pressure. Yeah, I guess those would be my two lessons.
Tyler Johnson: [00:45:06] Yeah. The two things I want to just sort of speaking as someone who's gone all the way through the gantlet that I want to just bring up in response to that. The first thing is that I want to go back to something you said at the beginning of the podcast, which the older I get and the further society gets into the 21st century, the more convinced I become that our unregulated, often thoughtless relationship with technology, especially smartphones and social media, is, I think, literally corroding our social world and corroding in many ways the foundations of society, which I know that probably sounds like a very dramatic thing to say, but I actually think it's true and from a personal standpoint. I'm just going to make a plea. Please do not spend your day off on your smartphone or your computer or whatever. I mean, obviously, some of that is probably going to be necessary. And maybe you want to blow off some steam by, I don't know, watching cat videos on YouTube or something. But I just think that there is something inherently nourishing about the real world that just can't be captured in a smartphone. And in many ways, we are all. Captives to our devices. Right? Because it's we're always looking for the next retweet or like or whatever the thing is. And it keeps us sort of in thrall to these little devices in a way that my personal experience is. That's exactly the opposite of what we need.
Judith Shulevitz: [00:46:48] Yes, I agree.
Tyler Johnson: [00:46:49] What we need is face time with real people, connection to real people. We need fresh air and and the sky outside and we need real life. Not what you can find on a screen.
Judith Shulevitz: [00:47:03] Well, if I may violate the sort of secular bent of this by saying "amen." I will say Amen. I could not agree more. I do think that this idea of isolation and social media go together because social media is isolating in a lot of ways. It fills a gap that friendship used to fill. I mean, obviously there are ways in which social media enhance friendship and expand your social circle, but I do think It does so at the expense of depth of connection.
Judith Shulevitz: [00:47:36] You know, another thing that happens during your bounded time, let's call it that, your and also your deepened time because it is a sort of deeper occupancy of time. You're not sort of distracted, right? You're not multitasking is emotional processing. So I do think a lot happens during that six day workweek that is super intense. And, you know, I don't really know what kind of emotional support a resident gets. My image of it is that it's not a lot. But, you know, a lot of very, very traumatic life and death stuff happens to you. When do you work that through in your own head. Let alone with someone else? It seems dangerous in a weird sort of way because you are dealing with life and death issues. And if you're sort of distraught and perhaps dissociating because you haven't confronted your emotions as a response to the things you've gone through, you're in a way a little bit problematic as a caregiver.
Tyler Johnson: [00:48:46] Yeah. So I just want to share a very quick story that I think illustrates that principle. There was a there was a person who is a fellow in our fellowship program. I'm one of the fellowship directors for the Oncology Fellowship Program, and I had sort of heard through the grapevine that this person had been subjected to some really inappropriate treatment from one of the attendings in the hospital, basically had gotten yelled at and dressed down in front of a bunch of other people for something that was not in any way the person's fault. The person had done nothing wrong but got wrongly sort of yelled at and dressed down in front of all these people. And I had sort of heard about this through the grapevine, and I had wanted to reach out to the person and ask, you know, sort of what had happened and whatever, whatever. And so this same fellow came to me one day in clinic and said, Hey, I wanted to talk to you about this case that we have in the hospital. And I said, okay, yeah, sure. And so we talked about the case, whatever. And then afterwards I said, you know, could we just step in this other little room over here for a second so that we can talk privately? And so we did that and we step into the room and I said, and you know, this is this person who had kind of sort of come buzzing into the clinic room and, you know, big smile on their face and and, you know, talking very competently and very fluently about this complicated case in the hospital, whatever or whatever.
Tyler Johnson: [00:49:59] So then we get into the other room and I say, hey, you know, I just want to let you know that I heard about this thing that happened in the hospital through the grapevine. And, you know, maybe it wasn't even a big deal for you, but I just wanted to kind of check in and, you know, see how you're doing and whether it was a thing and if it affected you and what I can do to help. And to make a long story short, this turned into a longer conversation. But within about three minutes, this person who I had never seen be anything other than composed, intelligent and downright cheery was just weeping because this truly terrible, inappropriate. Thing had happened. And to your point, there was just no space, let alone a place or a, you know, format or whatever to debrief it. Right.
Tyler Johnson: [00:50:45] Because it's just one of a thousand things that happens to you in the hospital on any given day. And, you know, absent any time or place to deal with those things, you just sort of push them down and push them down and push them down and push them down. All of which is to say this. The deeper point I think about my problem with smartphones, especially on the day off, is not so much it's not the smartphone or the or social media or whatever per se. It's that the thing that you need the most on your let's call your one day off a week, your Sabbath from being in the hospital.
Tyler Johnson: [00:51:18] Right? So if we think about that as your sort of medical, even if you like, secular, whatever Sabbath, the thing that matters the most in my mind about that is to be present. If you are outside, be present with the trees and the sky. If you are with your baby, be present with the laughter of your baby. If you are with your significant other, be present with the way that their hand feels in your hand. And in my mind, the great tragedy of the digital revolution is that it is almost entirely robbing us of the ability to be present. Nobody is ever where they are anymore, right? They're always on their screen flicking through whatever, whatever. And the hospital. It is so difficult to find presence there. Right? Because you're getting paged and you're getting called and you're getting asked questions and you're getting this and you have 27 things you have to do and you're screwing from place to place and checking box to box, all of which is maybe necessary to take care of patients and maintain your sanity. But it'll drive a person crazy. We have a deep, emotional, spiritual, physiological, I would even argue, need to be present. And so if you do nothing else on your Sabbath from the hospital, allow yourself to be present wherever and with whomever you are. That feels to me like one of the deepest needs.
Judith Shulevitz: [00:52:45] I think that's really profound and it makes me think that I didn't adequately answer your question of what would I take away from the Sabbath to recommend for somebody going through this intense experience to do on their day off? Because what you're talking about in terms of being present is being present with someone else face to face with someone else. And so there has to be a someone else. You know, the point I made earlier about the Sabbath is it is a collective time of rest. It is an organization of society that allows for community formation, community togetherness. So organize your time, coordinate your time, synchronize your time with the significant others in your life so that this can happen together. That's really, really important and often really, really difficult. I don't underestimate the difficulty of that, but it's part of the pleasure, right? Because part of the pleasure of being outside the hospital is spending time with this other person or people.
Judith Shulevitz: [00:53:46] So I would add that and I would also say, you know, there really are different qualities of time. You know, there's a famous historian Hobsbawm who, you know, distinguished between industrial time and pre-industrial time. And so, for example, you know, women at the time he was writing kind of functioned on pre-industrial time because they were responding to care needs. Which are not on the clock. A child is going to take as long as that child takes getting dressed, eating their meal. You know, it's just you cannot be chop chop about it. But patients are like children in that way. Forgive me for saying so. You know. They may be functioning in a different relationship with time or in a time that that has a different pace. And if you can't be present the way you talk about it, it's going to be hard to be present for that patient. So that's one way in which I do think this kind of time pressure affects patient care. You need to be able to slow down. I mean, you know, there's been tons of work on this, I'm sure. On the need to be able to slow down and hear what patients are saying. One of the one of the findings of some some important studies about altruism and compassion, that that is something that you can curtail when you're under time pressure. It's very hard to hear. It's very hard to listen when you're rushing because you're worried, you're anxious, you're thinking ahead. YOu're not thinking in the moment. So you curtail the empathy and the compassion you have for others because those are time consuming. You know, you have to hear them before you react to them. So I do think that is probably a patient care issue.
Tyler Johnson: [00:55:39] Well, and actually that is very much to the point of the podcast really the impetus for the podcast was in part to try to help us identify the the origins of the crisis of burnout in medicine. And even though we came to this in a much more circuitous way than we normally do, I think we've hit profoundly on sort of the core of what's going on there, right? If you put people in a situation where of necessity over the course of years, you deny them the ability to be present, then you rob them of the capacity to lean into and fully enjoy the very thing that makes medicine meaningful in the first place. The ability to be present with a patient is, even if they don't use those words, I think that is the core ideal that draws people into medicine. Whether you're going to be present with them as you do surgery on their eye or present with them as you treat their cancer or present with them as you take care of bringing their baby into the world or present with them as they are dying. It is that idea of shared presence with a patient that I think is really forms sort of the spiritual core of medicine. And yet we have inadvertently created a situation through the rigors of training and then through the corporatization and bureaucratization of medicine once you're in attending, that makes that almost impossible. And so I think that a wonderful place to sort of end this meditation together is to recommit ourselves on a larger scale. You were talking about unionization, and we've been talking about rethinking how training works and whatever to thinking. How can we do that collectively? And then on an individual micro scale, recommitting ourselves to making those, even if it is your one day off a week, making a Sabbath of that by being present both with the beauty of the world around you, and then perhaps most importantly, with the reality of the other people who are part of your community, whether that's your family or whether it's residents that you get together with on your day off, your co-residents, or whether it's your religious community or whatever it is. But I think that relearning how to be present so that you can make that day off of Sabbath, I think is a really beautiful and powerful idea. And we we really thank you for talking with us in a way that has allowed us to arrive there. Judith, you've been so generous with your thoughts and your time.
Judith Shulevitz: [00:58:16] Oh, well, thank you for having me. This has been incredibly informative and just fascinating. I think that in a way, doctors are canaries in the coal mine for the way we work today and what we're moving toward. So thank you for giving me this education.
Henry Bair: [00:58:32] Well, yeah, Thank you so much for for your time.
Tyler Johnson: [00:58:35] Thank you, Judith.
Henry Bair: [00:58:38] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsArt.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:58:57] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:59:11] I'm Henry Bair.
Tyler Johnson: [00:59:12] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.