Creating Sacred Space: Spirituality in the Medical Encounter—Part 1

Hineni—“Here I Am”: On Being Present and Sacred Space

Hedy S. Wald, PhD, and Aviad “Adi” Haramati, PhD

Hineni—“Here I Am”

It is a curious phrase that appears in Genesis, Chapter 22 in the Torah (The Pentateuch of the Old Testament). Within the story of the binding of Isaac, God calls out to Abraham, who then responds: “Hineni,” translated from the Hebrew as: “Here I am.” However, why does Abraham say that? Surely, God knows where he is.

Hineni is not about physical presence, Torah commentators state. Hineni is about being fully present and ready to respond. “I am at your service, your humble service,” is an offered translation. ¹ Rashi, the renowned eleventh century Torah commentator, explains the term as being “the response of the righteous, the language of humility and readiness.” ² When Abraham says, “Hineni,” he is saying I am fully present with all of myself, ready and willing, and open to what you might ask or say. I truly hear your call. ³ Within the Hebrew, the word Hineni is a contraction of Hineh (Here) and Ani (I am). Here I am. I am here.

The call from God (and Abraham's response) occurred prior to the command to Abraham to sacrifice his son. Abraham also replies “Hineni” when his son Isaac asks him where the sacrificial lamb is located as implements for sacrifice are readied. The father's “Hineni” resounds yet again when an angel's call instructs him to not proceed with the sacrifice of his son. The story highlights “themes of awareness, presence and intentionality.” ^{2 –4} The word Hineni occurs only eight times in the Torah and conveys “a significance of purpose, awareness and conviction, emphasizing the present moment and acknowledging how it came to be.” ⁴ Each time Hineni is used, “it signifies a turning point, a potentially life-changing moment requiring decision, action, and resolution.” ⁵

We were struck by this powerful meaning-making Hineni phrase and its resonance with our work in bringing our whole reflective self to healthcare practice and education. We were interested in the value of sacred texts as a springboard to think more and feel more about creating sacred space in clinical and teaching encounters (and in ourselves) for fully engaged, mindfully present, relationship-centered care and education. ^6,7 We let Hineni “work on us,” considering its personal and professional relevance as well as how we may be informed and even transformed.

The “speech-act” ⁸ of saying Hineni to another person, presenting oneself as available to serve, conveys “infinite” willingness to be available to—and for—the other person's suffering, as our responsibility. ⁹ Hence, we suggest, it is our intentional Hineni moment of mindful presence ¹⁰ —the being and the readiness to do (respond)—that creates sacred space within the intimacy of the clinical encounter, a place “worthy of or regarded with reverence, awe or respect.” ¹¹ Our own self-activation of Hineni captures an expanded view of empathy including both mindful focus on what a patient is going through and an action component geared toward relieving that patient's suffering. ¹² Such “therapeutic presence” influences the effectiveness of patient care. ^13,14 As the healers, we stand on a threshold of our own transformations within the experience of authentic connection and our Hineni response. ¹⁵

As educators in the health professions, we wonder: Within the Hineni context, how can we cultivate awareness and meaning-making for bringing our whole-person* (intellectual, emotional, social, spiritual) to whole-person care ¹⁶ with readiness to appreciate patients as whole human beings with unique lifeworlds? ^17,18 How can we cultivate whole-person education for educating our learners? How can we foster mindful, reflective practice to embody existential care that is therapeutic for the patient and satisfying for the healthcare professional? ¹⁹ In essence, what are best practices for preparing and fortifying our learners (and ourselves as lifelong learners) for the authentic Hineni moment?

Personal reflections emerged organically within our contemplation. We share with each other and we share with you, the reader.

“I Am Here.”

Hedy: A good friend wrote me that I bring “Hedyness” to the work I do. Ah—could she have meant fasten-your-seatbelt, living-life-on-three-channels, authentic-connector, “you must have passion, or you'll never accomplish the things that are essential,” ²⁰ Holocaust-survivor's–daughter, X-ray–vision, love-to-laugh/read/write, trust-is-my-middle-name, inhabit-the-music dancer, grandmother, naturally caffeinated, kaleidoscope me? It felt good to hear that. It was validating. I'm also, more recently, the wife/caregiver of a physician-now-patient with brain cancer. ²¹ We bring our stories to the work we do.

A surge of energy carries me into the room on my teaching day at the medical school, where I cofacilitate small-group sharing of reflective narratives in the Family Medicine Clerkship. I bring myself to create space in the curriculum for learners to slow down and grapple with “the becoming”—how they are thinking, feeling, transforming, what makes a difference, and what may hinder. Within intentionality of reflecting for deeper learning from experience, we are ready to share.

I want to hear more about the origins, the stories of their names, as they introduce themselves. As they divulge, I observe peers starting to see each other. Some laughter invariably accompanies opening our heads and hearts. I begin to gain a sense of who each of these precious doctors-to-be are, the ones who sent me reflective narratives about challenging patient care experiences, the people behind the stories on my computer screen. I've been thinking about the teaching relationship as sacred space—the “infinite responsibility” ⁹ to truly hear a learner, to coach, to respond. “Mirroring uncertainties that exist within clinical medicine,” I've written for faculty development workshops “we cannot be certain of where narrative will take us. It is our hope that, through reflective writing, we gain a fuller sense of presence and learn to see the Other [per Levinas ⁹ ] as we approach the mysteries of the medical universe—the patient's and our own.” Through the intimacy of the written word, we nurture our students and we nurture ourselves. I return home refreshed.

Adi: I am about to enter lecture hall LA-6, and I remember the first time I entered this auditorium at the Georgetown University School of Medicine, more than 30 years ago, with a sense of nervous anticipation and excitement. Standing on the stage facing close to 400 students (medical, graduate, and students from various programs), I look out to the audience and glance up at the attendees in the balcony. It is the first day of the course in human physiology—a course I direct. For many attendees in the room, it is the first day of the second semester, in their first year of medical school. They have had one semester of medical school and, for some, it was a shock to their systems—a new school, a new environment, and a strange new city. What now? This is the goal they pursued for so long; but, now that they are here, for some attendees, doubts set in. “Is this what medical school is about?” they wonder. All this science to learn, all these facts to memorize, but where is the relevance? “How does this relate to the patients I wish to help?”

As a renal physiologist and scientist, I am also a teacher at heart. An educator, the son of two educators, I was raised with an awareness that teaching is more than transmitting information—it is about transforming lives and inspiring hearts and minds. And so, I thrive on the challenge of taking material deemed “difficult”—perhaps even “boring”—by some people and making it come alive by encouraging students to be curious. My father would challenge me by asking: “Why should a student listen to you? Just because you are on the stage and in a position of authority? That is not enough. You need to make it compelling, so they will want to hear what you have to say.” The key, he continued, “was not how many were listening when you start, but rather how many are still with you when you finish.”

I am also now reflecting on a new way of engagement with students—our mind–body medicine skills groups that have been ongoing for the past 13 years. Envision 10 students with 2 faculty facilitators, sitting in a circle in an exquisitely serenely set, dimly lit room with fresh flowers and a flickering candle, all joined together in a hushed sense of sacred space as we gather to help each other grow and feel. This, too, is a place where medical education takes place; but here, we cultivate our souls and our spirits as we teach each other meditation, mindfulness, and other skills to enable us become more self-aware and empathic, and help our students develop noncognitive aspects of their personas.

So I take a deep breath, extend the exhalation to focus my mind and engage my spirit, and step onto the stage. Yes.…Hineni.…I am here.

“Here Am I.”

Hedy: Swish, swish, pop of the ventilator. I pause at the door to compose, to reflect. As the consulting psychologist on the hospital rehabilitation floor, I then enter the patient's room with a new means of “being there.” Necessity is the mother of invention when doing supportive counseling with patients on ventilators. This patient enjoyed poetry—sometimes. Today, that worked—his eyes softened, perhaps he was granted the gift of a mind vacation from suffering in that moment. On another floor, I share a laugh with an elderly patient who has not been laughing all that much lately because of pain issues. I noticed the “lipstick sign” of this patient caring enough to care about herself (applying makeup) and heaped on the positive reinforcement. It was a sisterhood moment. A Hineni moment.

These days, I spend time at another kind of hospital, a cancer institute. The kindness begins upon our arrival as we are greeted by a fully present valet parking attendant who gently assists my husband with his rolling walker. The pace is slower in the illness universe, all we have is the moment. Respect for our ordeal is palpable in the verbal and nonverbal—I experience the quiet in the elevator as a sacred hush. Judy Collins sang: “I've looked at life from both sides now.” ²² Indeed, this unimaginable life narrative is now within the fiber of my being. My husband inhabits each moment and encourages me to do the same, to expand my work, and to continue to create.

Within all of this and students' narratives about their experiences as reflective triggers, we have discussed that connection is not necessarily the same as communication. Our full Hineni presence precedes the “transcendent act of compassion, the root of healing.” ²³ Are you present with the suffering? Can you hear the “primordial call of the sufferer” ^9,23 and be ready and available before you even know whom the patient is?

Adi: I reflect back to March 7, 2011. Ten days earlier, the integrated module I now direct on renal and electrolytes was completed, and the final examination scores were high. I remember feeling deep satisfaction that the students showed that they truly comprehended the information and learned to think critically. Yes, it went well.

And yet, late that Sunday evening, satisfaction turned to pain—that familiar, dreaded dull ache in the lower left quadrant. Oh no, not another kidney stone! Yes, I often joked with students about the irony that the “renal guy” forms kidney stones, but, focusing on the positive, I usually followed quickly with “better flank pain than chest pain.” However, this time, intense pain, nausea, an emergency room. I was seen quickly and treated appropriately but was getting worse not better. Three hours later—I suffered a heart attack. No chest pain—just profuse sweating and nausea. This too was a Hineni moment—absolutely, I was in the here and now. The next several hours were a blur: consultations with cardiologists after the imaging; the helicopter ride to another hospital for surgery; the skilled competence of all the medical personnel; and waking up feeling very, very grateful. I am still here…in my unanticipated Hineni moment.

I also remember the recovery, getting over the extreme fatigue and beginning to insist after 3 weeks that I could drive to Georgetown to join my mind–body group. The students and my cofacilitator colleague were very worried and sent me a mind–body kit: complete with candle, flowers, and chocolates, just like we set up in the room at school. I was resigned to taking the time at home to recover appropriately, but I also felt a need to join the group once I had the strength. And so, at the 3-week point, with great care, and having my wife on speaker phone the entire drive to Georgetown, I took my place in the sacred circle with the others and, after someone lit the candle, began to focus on the breath. Breathing…living…gratitude…this was an overwhelming Hineni moment.

“We Are Here.”

Hedy: I thanked Dr. Aviad “Adi” Haramati for his offer of a mind–body curriculum outline on a medical educator list.serv and introduced myself. “Thank you for reaching out,” was his warm response, sparking an engaged conversation that continues to this day. I told him about my work and I told him about me. He told me about his work and he told me about himself. I had been thinking about potential connections between mind–body skills and interactive reflective writing to help promote learners' mindful, reflective practice and resiliency, but it had not yet taken form. Within the creative connection and collaboration, each of us is present, open, and ready to receive input from each other, standing on a threshold of transformation. ¹⁵ We merge our ideas, and the work is enriched and so are we. We craft a synergistic skill set, a “toolkit” for ideally fostering awareness and meaning-making, and we are ready. We arrive in Israel to share this work and share our personhood with healthcare professions faculty members and students within experiential sessions. I softly utter the Hebrew blessing of Shehecheyanu: “Thank you G-d for bringing us to this time,” to this moment, to a shared and now expanded collegial Hineni moment as well as to our readiness for the learners and, ultimately, for their serving patients and the society at large.

The Ben Gurion University students complete the meditative experiential component with Adi, and then, it is my turn. I experience joy while facilitating these engaged learners' sharing of their reflective writings about meaningful care experiences. There is meaning in the writing and in the sharing. To be a doctor, to be a human being—maybe this can make a difference.

Adi: Who is this Dr. Hedy S. Wald who emailed me after I posted on the DR-ED list.serv about our mind–body medicine curriculum? I knew that name—a clinical psychologist from Brown University, who was published on narrative medicine and reflective writing. How interesting it was that she wanted to know more about our program. Although we had not met, I knew about her from mutual friends here and in Israel. Perhaps this was an opportunity to synergize approaches and interventions with students? So, we set up a time to speak by phone and it became clear very quickly that there was a meeting of the minds. With the energy, the creativity, the different perspectives, we could do some good work together.

And so workshops got planned, grants got written and we found ourselves in Beer Sheva, Israel, at the Medical School of Ben Gurion University, giving a joint workshop on the mind–body connection—blending mindfulness and reflective writing to reduce stress and foster resiliency. We worked well together—collaborating with respect, challenging each other, and implementing something very unique. I led the meditation, but more importantly, I was learning. And the students seemed genuine and happy and engaged in this sacred space. It was another extraordinary Hineni moment! How “cool” was that?

Back to the very beginning, the “Genesis.” Through Hineni, we have the opportunity to inhabit and bring our most authentic self to the other with moral alertness, emotional readiness, and a strong sense of presence to the moment. ²⁴ We become more refined versions of ourselves, the best we can be, “when we are present and intentional in our thoughts, feelings, and actions.” ⁴

Pause. Entering the exam room to greet the patient, enriched and fortified with mindful, reflective skill sets and honed technical skills, we are ready. For the science and for the existential. Creating sacred space as we capture a Hineni moment in the spoken and the unspoken, “I am here.”