Who By Fire?

Thoughts on Doctors, Leonard Cohen, and the Yom Kippur War

As usual, Fall came out of nowhere.

I left the house early one morning to walk Dakota, our red tri Australian shepherd, wearing my usual cargo shorts, T-shirt, and reefs, when a cool breeze hit me and suddenly, just like that, I knew that summer was over.

Maybe preparations for the start of school should have tipped me off. Or the return of students to the Columbia campus. Or the sudden scarcity of parking spots. Or the upcoming Jewish holidays.

We are currently in the ten days between Rosh Hashanah, the Jewish New Year, and Yom Kippur. It is said that God decides our fate and inscribes it in the Book of Life on Rosh Hashanah, and we have ten days to appeal it before it is sealed with a blast of the shofar at the close of Yom Kippur.

There’s a famous prayer in the Yom Kippur liturgy, Unetaneh Tokef, that hauntingly expresses the sense of human frailty and mortality that fasting and praying on Yom Kippur is supposed to evoke. If the prayer itself is not familiar, you’ve probably heard Leonard Cohen’s version of it in his 1974 song, Who by Fire, or at least PJ Harvey’s cover of it in the AppleTV+| series Bad Sisters:

And who by fire, who by water

Who in the sunshine, who in the night time

Who by high ordeal, who by common trial

Who in your merry merry month of may

Who by very slow decay

And who shall I say is calling?

There’s a good story behind the song.

In 1973, Cohen was in crisis. He was living on the Greek island of Hydra, miserable in his marriage and feeling trapped by fatherhood. He was repelled by fame and artistically blocked, determined to leave the music business for good. A classic mid-life crisis.

Then, in October of that year, a coordinated coalition of Arab states invaded Israel on all fronts in a surprise attack on Yom Kippur. Impulsively, and perhaps self-destructively, Cohen booked a flight directly to Tel Aviv. A group of young Israeli musicians recognized him sitting forlornly in a cafe and took him with them to the Sinai desert.

What he experienced there changed his life.

Cohen found himself on the front lines of an epic clash between the Israeli and the Egyptian armies. The very survival of the young Jewish state was at stake. He met hundreds of Israeli troops, many of whom were later killed in action. He witnessed Israel buckle under heavy losses of men and equipment before finally turning the tide of the battle.

By all accounts, he touched the soldiers he met there and they touched him. “I came to raise their spirits,” he later said, “and they raised mine,”

A personal and artistic renewal followed. A year later, back in Greece and clearly influenced by his experience in the Sinai, he wrote Who by Fire. He and his wife expanded their family with another child, and he went on to produce the greatest songs and albums of his career.

What was it that shook him out of his funk? What did he see?

Certainly death, destruction, suffering, fear. Probably also bravery, heroism, comradeship, and love. What he took away, judging from his song, was a heightened sense of a brutal reality: we hang by a thread, which may feel strong, but can suddenly snap without warning.

Cohen witnessed the worst and came out as a better, more enlightened human being. Well, if that’s what it takes for enlightenment, aren’t doctors lucky?

Like Leonard Cohen in the Sinai, we have a front seat to the worst aspects of the human condition: the mother with a stomachache who turns out to have pancreatic cancer; the valedictorian high school student who collapses in front of her parents and turns out to have a malignant brain tumor; the star teenage athlete with swollen glands that turn out to be filled with leukemia.

And yet we doctors, as a group, are hardly enlightened.

If anything, we tend more toward anxious, depressed, and disillusioned, with 15% of us suicidal by some counts. A new study based on ten years of data just came out of Stanford showing that physician burn-out, already high to begin with, has risen to alarming levels in the wake of Covid.

Why is that?

Everyone has a pet theory and there is some truth to all of them. Mine is that, as opposed to Leonard Cohen, who had a distinctly spiritual bent, doctors are selected and trained to be high priests of scientific materialism.

To be sure, when it comes to medicine there’s nothing wrong with science or materialism. If you want to analyze and manipulate the physical world, which includes the human body, it makes sense to view it from the perspective of physics: a fact is true only if it can be measured, and a theory is true only if it predicts measurable and reproducible results.

The problem is how quickly and easily the materialist perspective seeps out from medicine and science and into other areas of human life – and death. Once you are trained to see the world in one way, it’s not so easy to shift gears and see it in another.

When I was a resident, I remember thinking how weirdly disconcerting it was that vital signs were recorded more frequently as the patient approached death. On the regular floor, vitals would be taken every four hours. If the patient started to deteriorate it would increase to every hour. Then every fifteen minutes. Then, if the patient ended up in the ICU, it would be continuous.

In the context of what we were doing, taking vitals made sense. But in another context it was absurd, an escalating obsession with the material as the patient transitioned to the immaterial. Anyway, certainly not the way that I would want to be treated at the end of life.

Since then the new field of hospice medicine has mitigated this absurdity. But as much as we praise hospice, the honest truth is that for most doctors, the idea of their patient ending up in hospice carries a whiff of failure. You can see this by how quickly they tend to disappear from the picture once that transfer occurs – out of sight, out of mind.

However you slice it, the scientific materialist view of the world is kind of depressing. At the end of the day, we are all subject to the second law of thermodynamics: time’s arrow moves inexorably toward entropy and the unstoppable, meaning-free dissolution of everything.

Contrast this with the Western spiritual tradition. God created the world, with all of its physical rules and laws, and maintains an active interest. Human beings have souls, and free will, and operate within a moral system of divine justice. Everything has a purpose, whether apparent or not, and death is not the end of the game.

Or contrast it with the Eastern spiritual tradition. Everything is transient, impermanent, and in a constant state of flux. Suffering stems from a craving for permanence and can be transcended with practice, compassion, and ethical behavior. Oh, and death is not the end of the game.

None of these worldviews – Western, Eastern, Modern – are mutually exclusive. On the contrary; Leonard Cohen was influenced by all of them. A modern man, he was raised as an Orthodox Jew, and later went on to become a Buddhist monk. And judging from his work, Cohen brought all three to bear on his life experience.

Do doctors have anything to learn from him?

At least this: when it comes to deciphering the mechanics of the world, nothing beats physics; but when it comes to making sense of it, to flourishing in the world – or in spite of it – metaphysics should be seen not just as complementary but as essential.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
This blog will be a mix of stories, advice and discussion – topics will diverge widely, but they will all share a point of view!