Electronically Challenged

It took a geek to make my new iPod functional.  It's still not entirely functional.  Electronic Medical Records as I have used them the last three months impede my ability to think about patients.  My three computers, the main one, my laptop, and the one on my desk at work never seem to work at peak function.  And I get ripped off for most of the services I am compelled to purchase for these.

In a prior generation, when I was a potential geek on the sidelines, it was the cars that got enthusiasts enthused but irritated the rest of us by costly breakdowns for which we were dependent on people a little outside the main stream to get us mobile again.

My patients may have similar comments about me as their Patient Repairman.  I did not create the complexity of their physiology nor did I cause its malfunction, at least not initially.  Things are generally repairable and upgradable.  I do not perceive doctors as geeks the way I regard computer experts or auto mechanics, though the public may not concur.

This new calendar year, I will make a better effort to understand my electronic resources and bodily resources and use them in a more functional way.

Happy New Year.

Too Irritible

These past few weeks I've felt a little jumpy and perhaps hypercritical of what goes on around me.  It's hard to tell why, but small things irritate me.  My neighbor Reb Yaakov, the great sage of Monsey, used to get transported in a clunker that often failed to get to him to his desired destination at the desired time.  He used to shrug it off as HaShem's desire for him to be someplace different than where he wanted to be.  Things that don't work right or people who don't do what they are supposed to do might be part of a divine plan or plot.  Still, I greatly prefer to have what I need when I needed, to have nurses that give medicines at the appointed times and record on the record the things that need to be recorded, patients who keep their appointments, fellow denizens of the highway who share my interest in safety, Rabbi's who know enought Torah and have the intellect to discuss it, Board members who can go beyond nice as an end point.  It could be a lot worse, unlike the political wingnuts, Obama's decisions and Talk Radio do not get me emotionally involved at all.

I think my failing comes from not being able to separate things that I control and are amenable to correction, which should irritate me, from things I am not able to control but would still like to.  Finding what I need when I need it falls into the realm of possible, however prolonged the problem and unlikely the resolution.  As I learned this week, my iPOD may frustrate me but there is a geek at Best Buy who can make it work, or at least move me into the world of possibly having it function.  Blocking ladies with 425 SAT's from completing nursing school cannot be on my personal agenda.

Winter Storm

For my first nineteen years of practice, somebody else took weekend call when the big snowfall hit, then last year, my final one at Christiana, the lot fell to me.  I stayed overnight there for two nights, handled one emergency from ten miles away and scratched the fender of my car on a snow bank.  Now I am in Philadelphia where I take call half the weekends so having to cope with the Big One becomes inevitable.  So it is this afternoon.  I knew that the white downpour would arrive at about mid-day so I went to Mercy Philadelphia Hospital a little earlier than has been my Sunday custom, saw all the follow-ups and three new consults, then headed home with the expectation that I will be devoting tomorrow morning to shoveling rather than office patients.  I'd have closed my own office in these circumstances as few people can get around, though a few hardy folks always manage to show up.  Somebody is on site at the hospital so people receive the care they need though often from somebody who will need to catch up on sleep as soon as the relief crew arrives.

This time also offers an opportunity of a few hours without the usual intrusions.  It becomes a chance to do things that are important when most work days are devoted to shuffling the urgent.  Time has come to set the semiannual tasks, work on my two upcoming talks, tone down my ornery disposition by a vigorous session or two with a white driveway.  No need to arise as soon as the alarm buzzes tomorrow.

Taking Shabbos Off

Even when Christmas comes on shabbos, the Jewish doctors take weekend call, as I have done every year since starting practice in 1990 and all years but one since my internship.  This weekend, the legal holiday was Christmas Eve, a Friday, when I went to the relatively quiet hospital, saw a couple of new consults, rounded on a dozen more and drove home for a quiet shabbos dinner at services at Beth Emeth that failed to materialize.  Their intermarriage situation may be more profound than I realized.  Logistically it makes most sense for me to take Saturday call from home, which I did, then round and see new consults on Sunday, which is how I usually have been handling the weekends at Mercy.  Only one consult came through, no other calls.  It was my original intent to do nothing.  Instead, I caught up on decluttering, moving a few loads of papers to the recycling bin, putting away most of my clothing, creating a PsychoPath in the bedroom.  I did not go to services.  The Rabbi would wonder if one of the Jewish doctors showed up.

Synagogue's Core Business

The AKSE Board voted unanimously to renew the Rabbi's Contract.  That part was a no-brainer as he fulfilled one of the prime missions of AKSE with excellence.  There are severe financial limitations with expenditures exceeding revenue.  For years the Board of Governor's, of which I have been a reluctant part, has focused on increasing revenue, from a Capital Campaign which was intended to have nothing to do with operating expenses other than eliminating mortgage payments to enhancement of membership census.  That meant having an ambassador to the community with a pleasing personality that can attract members.  For the first time in years, the membership list has expanded.  No question that changing Rabbi's would interrupt the intent of the leadership.

However, stabilizing finances should be a means to an end, which is the operation of the services that the synagogue provides, particularly those things not attended elsewhere.  I am not sure that the Executive Committee which really has the responsibility for doing this really sees it that way.

There is probably some diversity of opinion as to what the mission of a synagogue ought to be.  I do not think AKSE ever developed a mission statement that could hang in a frame on several conspicuous walls for all to see or that can be printed on the letterhead or agenda of each Board of Governors meeting.  Having community outreach or a mascot is not the mission though it may enhance it or enable it.  The growth of transdenominational Jewish groups separate from denominational label suggests that there are no services that can only be provided by synagogues.  In most American communities, where early settlement records are available, the first project of each new community was to bury its deceased, which has some urgency to it.  Therefore the first communal effort was to purchase land for a cemetery and form a burial committee.  Even now, those unaffiliated with synagogues still have Jewish funerals with burial in Jewish cemeteries so a synagogue is not really a necessary institution even at the time of most immediate crisis.

At the last AKSE Board meeting a new grandmother described her son's community gathering on its own to attend the bris.  That particular community was generated by the synagogue, so one potential mission might be to gather subsets of Jews to better enable loyalty to each other.  Transdenominational groups which in some communities have siphoned both talent and membership dues from are synagogues, the Conservative ones in particular, have almost gone into competition with them by providing a better product at a lower cost. 

I think that the role of the local synagogues not fulfilled elsewhere would be to offer a measure of security for observing major life cycle events and offering a place to worship.  Assembling a community and advancing the Jewish capacity of its participants would fall into the next tier.  My report card on the Rabbi is very mixed, particularly when growth of membership for its own sake is not part of the core activity.  Life cycle events, other than assembling minyanim at the synagogue for those reciting Kaddish has been predictably available, no more and no less than previously.  Too often the worship experience has been numbing more than fulfilling.  I do my learning elsewhere, something that has become very easy in this world of electronic resources.  Groups have assembled more than before, though I am not currently part of one.  I've not sought one out and none has sought me out.  Very mixed assessment though I concur with the majority that it would be a mistake right now to direct attention on AKSE's core business.

Membership Mentoring

Our sages noted that no two people have the same voice, appearance, and views.  At AKSE I find myself generally critical, almost to the extent of the American politicians who seem almost programmed to oppose what is set before them by people of opposite views irrespective of its merits.  On the other hand they have enough cheerleaders but too few careful analysts.

The Rabbi and President decided that they needed a mentoring system for new members and went about recruiting veteran members to take newbies under their wing.  A list of new members, just shy of forty was sent out.  For all the effort of recruitment, there really weren't that many.  The majority were relatives of families signed themselves up as members.  One is 90 years old, another not that far her junior.  By my head count there were about three who were entering their prime with the talent and energy to allow the generational turnover to proceed in a way that improves upon the present.  To my assessment, that is not Membership Committee success but more accurately the illusion of success.

And they are attempting to socialize the folks to the AKSE way Federation style with a genuine Federation facilitator.  That process has led to the destruction of a generation of non-orthodox Jews.  Federation locally never got its young people of major talent to sign on and the Conservative movement similarly sacrificed its talent by setting a clear priority for loyalty over ability.  All appearances are welcome, but not all views.

I think it time to sit out a few weeks, perhaps the month of January, and decide whether $2000 could be better spent not only on my own Jewish advancement but on support of institutions that can distinguish between real success and its illusion.

Adopt a Family

Mercy's Endocrine section manager sent me an email that the group was providing Christmas presents for a local family, assigning me a 13 year old boy, who I know nothing about.  This being my first time, I asked the manager what the minghag b-makom, or local custom, happened to be.  I was mostly concerned about amount, eventually learning that my partner sent a check for $50.  While I like to give money as wedding gifts or even Bar Mitzvah presents where the funds can accumulate and the recipient starts out with savings or tuition, for events that will occur again, like birthdays or holidays, I prefer to take the opportunity to think about the recipient and how I might add a some form of more short term pleasure.

I know this fellow's age and that his family is needy.  No other information.  I do not even know if he is Christian and celebrates Christmas, as the West Philly area has a fair number of Muslims, either from an enclave of Bangladesh or African families, or African Americans who discovered Islam in the state or federal correctional facilities and who found the requirement for abstaining from drugs and alcohol useful for their future or maybe who found the doctrine of selective rationalization of violence attractive.  I know nothing about the recipient.

While it was my natural inclination to spend all $50 on a single gift, figuring that he'll never accumulate that sum to spend on himself, my wife, who has done this before, recommended that I divide the total into three gifts.  The office manager concurred with my wife, so I did. 

Several years ago the Jewish Theological Seminary's TOR-CH posting site contained a thread in which two orthodox missionary types electronically heckled the Conservative institutional structure and the mediocrity or less that has accrued from it.  The more capable of the two commented to me privately that he really wanted the Conservative participants to upgrade their Judaism properly which in his mind meant being more like him.  I politely responded that the goal should not be to have them more like him but better reflections of their own aspirations.  Gifts can get into a parallel trap.  I would like this early teen who I know nothing about to be inquisitive, creative, studious, responsible, all the things that I admire and then project upon him, though maybe not what he admires or even fulfills the intent of pleasure.

In the end, I divided the allotment relatively equally, settling for a Phillies sweatshirt where one can never go wrong, a telescope, and a soft-tipped dart board.  It does not fulfill any of the criteria I set ages ago for gifts for my secretary's son, who I do know, which must either make noise, get him suspended from school, or bring him to the ER.  None of these for the anonymous recipient.  Unless maybe if his evolving hormones and id prompt him to use the telescope to forgo looking  at the heavenly bodies in favor of a more earthly body belonging to cute chick in the apartment across the street.

Artifical Contentment

I ingested my last Celexa tablet a few weeks ago, part of a drug holiday I gave myself after muffing a scheduled platelet donation last month by mindlessly taking an 81mg enteric coated aspirin tablet that I neglected to omit from my weekly pill case. So until the next platelet donation last weekend, I treated myself to a drug holiday. No aspirin as the blood bank program requires but also no statin, PPI, multivit or SSRI. Other than some wicked heartburn tided over by antacids, while disabling initially but just slightly annoying at present, no medicines. Yesterday, I restored the pill case with all but the SSRI. Aspirin and statin have evidence of life prolongation and other than some achiness early on as the Crestor dose was increased, there have been no adverse effects, though I always wondered if I really would need the PPI if I deep sixed the aspirin. I accept the endoscopist's finding that there really is some reflux but no Barretts, so both the aspirin and omeprazole returned to the pill case. I have a whole jar of OTC house brand men's formula multivitamin, so that went back to the pill case too. My citalopram tablets, even though of ample supply, stayed in the amber tube that I got from the Super G pharmacy a couple of months ago for $10.

Other than some annoying reflux, I clearly feel better without the medicine. It has been a tenuous course with the SSRI, starting many years ago with Prozac samples from the office, then Paxil samples which made me feel drugged and finally Celexa samples which became the generic citalopram. It is not my first withdrawal but unless a lot of people start complaining about me I do not plan to return to this medication.

Peter Kramer in his Listening to Prozac best seller of twenty years back described using the medicine for Obsessive-Compulsive Disorder, which at the time was an experimental use, and for which I worked out with my doctor my first trial of it in the 1990's. Dr. Kramer described Tess who became charming and sociable. I did not become charming, or at least nobody gave me feedback. What I became instead was dulled, almost emotionally neutral, without placing a value judgment on it. Irritants no longer irritated me. My patience improved and I could read or watch TV for longer periods of time with greater safety than if I had tried to achieve the same result with ADHD agents. In exchange for some form of artificial inner peace and perhaps a slightly better attention span, my mind wasn't as sharp. I had no particular inclination to look up medical information I did not already know. My abiltiy to write in an incisive way and to follow thoughts in sequence declined dramatically. Moreover, I felt tired, this being the symptom that prompted each of the previous withdrawals and return of irritibility guiding each restart.

So now I again find myself able to think clearly with very little inhibition to my natural candor. I am less tolerant of myself for not accomplishing at the end of the day and less tolerant of others who now irritate me.

Another book on the subject, Artificial Happiness, comes from Ronald Dworkin a few years ago. While the writing and analysis seem almost primitive next to Dr. Kramer's more elegant prose, he makes an important point that sometimes life's goals are best persued while irritated. If AKSE leaves me unsatisfied and treats me like a picador with multiple little sharp provocations, then using a pill as a surrogate to disaffiliating when I should diminishes my Jewish future. While patients may also irritate me more, I owe them the full measure of my skill which should not be set aside for my own inner peace. As I compile my intentions for the next six months I really want to work on conducting myself in a more gracious, less abrasive fashion than has been my history. But I need to give myself a genuine chance to do this without the phony pharmaceutical restraint.

Danny's Four Questions

"He (Chanina ben Dosa) would also say: One whose deeds exceed his wisdom, his wisdom endures. But one whose wisdom exceeds his deeds, his wisdom does not endure"  Avot 3:10

As I do the semiannual planning it essential to keep in mind that when the six month review occurs, we are the things that we do, not the things that we intended to do.

So far my intentions for the first half of 2011 include decluttering the house, using an iPod to advance my path to sagehood, preparing for my Board Exam, meeting a variety of health end points, completing and implementing my post-retirement financial program, and nurturing a more gracious presence.  That is the wisdom that will not even arrive, let alone endure without some very specific means of doing them.

A passing acquaintance, Danny Siegel, an awesome sage who has devoted his energy to getting Jews to incorporate tzedakah into their usual activities, once sent me a note in response to a donation I had made to his Ziv Tzedakah Fund.  It being the Pesach season, he included a brief article he had written about Danny's Four Questions.  Years later, at each planning session and at each life's branch point, they still guide me.

What do you like to do?
What are you good at?
Who can help?

Why not?

Semi-Annual Planning

Each June and each December I allocate a fair amount of effort into defining six finite, measurable projects that would advance me if I actually did them over the following half year.  Usually only one has a real deadline with an inevitable end point.  That one always gets done, whether it be celebrating a milestone anniversary or arranging a child's Bar Mitzvah.  Most other things don't exactly end up getting procrastinated but never arrive at the pre-determined end point either.  I always fall a couple of publications short of my usual goal of four, my finances get turned over to an expert but I never actually complete the estate planning that I had intended, some physical ailment crops ups that gives me an excuse for not meeting my exercise targets.  Still, it is good to have a tangible measurable goal with a deadline to better enable some form of direction and prod to get there.

Usually it is not hard to get to six, some like repackaging intentions for better health or less random financial management in some form.  For the past six month block, I started my new job, got my name in print only once but got three medical opinion pieces onto the electronic journal.  My future financial needs of estate planning and long term care insurance will remain undone by New Year's Day.  My weight is a few pounds above where it was in July and as in past years, my treadmill has become one more flat surface to put stuff on.  There is usually a home upgrade on the list, this time to create a sanctuary for myself in my bedroom.  The semiannual home upgrade project almost never gets done, whether dependent on me or a contractor.  I tend to waver back and forth in its process, much like approaching anatomy, which can be taught either regionally or by systems that span several regions.  I can either make my bedroom sparkle or I can rid the house of clutter wherever in the house unneeded stuff happens to be.  I've tried both, neither effective.  And by the end of the half-year, the sixth project has escape my immediate consciousness but is easily recalled by a glance at the 3x5 index card that I keep with the page marker of my Franklin Planner.  Oh yes, it was to have a blog that other people might want to read.  The postings are regularly implemented, the readership spotty.

So what do I hope my life will be upgraded to by Independence Day 2011?  I will weigh less by intent, though the process for getting there still needs to be worked out.  Upgrading rooms has been a sufficient failure that I will need to do something regionally this time.  Now that I am earning a very substantial wage without the intrusion of running my practice, it is time to set a higher priority to this than I have been doing.  There is always some form of mental advancement project that I really work on.  The time has probably arrived to get some modern electronics such as iPod or iPad or Smart Phone to better enable this, though I've encountered a fair number of people who I think are not smart even though their phone is.  What has not been on the intermediate goals in a while is some form of Jewish advancement.  Slouching in level of observance would make for a good topic for one of the three essays I intended to write but didn't.

Bimah Me Up

Many years ago a number of teachers guided me through some skills that would enable me to contribute to worship services, though the activities lay dormant and unrefined for many decades.  As a senior resident I accepted a haftarah invitation, then some invitations came along for Torah reading.  Functioning as shliach tzibbur never garnered an invitation, other than maybe maariv at a house of shiva or a Kabbalat shabbat when the hazzan was away.  A couple of years ago, the gabbai got desperate enough to recruit me for Shabbat morning, which takes a little more preparation than the others.  It went OK, though with far less proficiency than I had acquired with Torah and Haftarah reading.  Time lapsed, then another invitation a few months ago, then they needed to scrape a little farther into the cadre of skilled men who get up that early on a shabbos morning so another invitation came.  Unfortunately, the gabbai also botched the schedule, putting his son in the slot that had been set aside for me.  I accepted a rain check for two weeks hence, which is tomorrow.  I forgot at the time that this shabbat coincides with Hanukkah, so there are two additions that I had never done before:  Hallel and Al Hanisim, which I had to learn.  Most of Hallel I already knew as the tuneful parts are publicly recited.  I just needed to learn a basic nusach for the brachot and chatimot, which was readily available from a number of audio sites online.  Al Hanisim I was on my own.  Last evening I went through the dry run for the first time.  Not elegant, but not tircha d'tzibburah either.

For a congregation that either prides itself or deludes itself into thinking it has a monopoly on serious Jewish talent in our community, the evidence is that AKSE has not done an Ace job in expanding the proficiency that its members bring to the sanctuary.  There are a handful of Bar Mitzvah boys who perform capably, though in a limited way, recycling what they learned for their bar mitzvah when convenient, though for all practical purposes never learning a new Haftarah or Torah portion.  When the hazzan goes on vacation, he has to hire a Torah reader, one from the Conservative shul, setting aside all his semi-public contempt for inferior conservatives, whose alumni like myself allow AKSE to function from one week to the next.  And the unwillingness of the women to advance their skill beyond a Junior Congregation level and the complicity of the Rabbi with this classifies as an institutional shonda from my perspective.

So while those who come early enough to hear what occurs prior to Torah reading will not exactly experience an audio treat, they will have a relatively rare opportunity to listen to an effort to advance skill, one performance that did not derive from the Davening Recycling Center.

Hanukkah

We lit the first candle last night.  This year, in our silver oil menorah, we used shabbos candles instead, as the oil can be quite messy and the shul's gift shop did not have any this year.

Hanukkah has multiple themes:  victory by underdogs, living on one's own terms, recognizing the value of small amounts of good oil when usable but defiled oil exists in abundance, adding a new candle each night as there is more to celebrate as the days proceed.

In the late afternoon, not long before the sun set, one of my favorite pharmaceutical rep pairs who used to call on me to Wilmington stopped by the suite at Mercy to deliver some Novo insulins and Victoza samples.  I was having a wicked day, ultimately seeing a personal record of eight consults before I departed for home long after most people had kindled their first Hanukkah light and munched their first latke.  I interupted my tasks in the hospital to visit them for a few minutes.  Drug reps make good spies, since their rounds take them to many places and they hear a lot of candid comments from doctors and office staff.  So I caught up on some poop at Christiana and the welfare of my former colleagues.  While I am rather content with my surroundings, despite not having the day to day control of my activities that I had in my own office, I've been treated rather well thus far and really like the people I've met along the way.  All eight of the patients I saw as new consults probably benefited from what my skill provided them.  I suspected that my colleagues at CCHS struggle more with their employer than I do with mine.  That turned out to be the case.  I think at least half of them are virtual serfs, tilling the exam rooms and wards under difficult circumstances, seeing large volumes of patients who get processed through more than they receive the individual attention than my partner and I are able to give and who need the medical care a lot less than most of the people that I have been seeing.  While my path of least resistance as my office became less viable last year would have been to have them annex me, that shidduch was not to be.  Those left on the outside but with a mission in mind sometimes really do triumph over the dominant players.

Getting Up Early

My internal clock may be malfunctioning.  Early to bed, early to rise has altered my schedule without contributing a whole lot to health, wealth or wisdom the past few weeks.  As the clock moves toward 5:30, I've been up an hour, did some milchig dishes, made the crust for a Bookbinders Apple Walnut Pie that I've been meaning to make a gentleman who helped Irene out when her car malfunctioned last month but have not yet embarked on the planning for the upcoming week and month that was supposed to have been done two days ago.

Everything seems quiet with the sun not yet risen and no audios turned on.  A day of opportunities to do things, both to set goals and pursue them, has hardly started.  Coffee goes well this time of day, its attraction today being its pleasant but slightly bitter taste more than the need to perk up more than I am right now.  For a brief time, at least, I do not perceive myself as overwhelmed.

Thanksgiving

While my tendency is to be a kvetch, as tochacha is always the first step to improving most things or most people as the Sages suggest, there are times to break from this pattern.  My American and Jewish cultures set some time on the calendar to enable this.  The American one, Thanksgiving, arrives tomorrow and one of the Jewish ones, Chanukah, comes next week.  Tal Ben-Shahar, in his PBS Special, suggested keeping a daily log of Hakaras HaTov, five good things that took place each day.  I keep my log in a grade school composition book obtained in the back to school sale.  It is very sporadic in entry dates, though I am fortunate that I am never at a loss to come up with all five.  These entries are always a look back, though, never anticipation of the good that might come my way tomorrow.  As the wise character Alfred Doolittle noted, "the Lord is throwing goodness at you but with a little bit of luck a man can duck."

Since I cover Xmas each year, I can always expect Thanksgiving as a day off, though this year only the one day.  The menu has been planned, the kids arriving from NY at some point, and a marathon of enjoyable meal prep and eating awaits.

Dad's First Yahrtzeit

Dad's first yahrtzeit came and went, uneventfully.  I said Kaddish last shabbat, though the actual observance with candle began the Wednesday night before.  AKSE never put it on their calendar, so no notice went out.

For my mother's observance, which will reach forty years this winter, I have received a notice from the JCC of Spring Valley or its current incarnation every year, at least since residency and maybe as far back as medical school.  I send them a check each year, a small one, but enough to maintain me on the notification list, even though I've not been a member in decades.  Then again, she has a memorial plaque there.  At Beth Shalom, I received a reminder each year of my membership there and same for AKSE.

But AKSE has no organized mechanism for entering new data.  Presence of mind would probably suffice as Dad's passing was announced from the Bimah on the day of death and they held two shiva minyanim at my home.  But nobody had the presence of mind to enter it on their computer data base which meant nobody had the awareness to request a donation or ask me if I needed assistance in assembling a minyan.  In the absence of thought, automated procedures become a reasonable surrogate.  This apparently does not exist.  My kids never have their birthdays announced in the Shofar, nor do anyone else's kids, even though a number of namings and bris ceremonies have taken place there, to say nothing of Bnai Mitzvot that where dates are assigned years in advance.

The consultant a few years back commented in his official report that many of the procedural aspects of AKSE's operation seem random when they should be consistently predictable.  Entering dates may be one of them.

AKSE's 125th Anniversary Celebration

The preparation and event have come and gone.  I think people enjoyed the evening.  I've not had prime rib in ages but I can see why its popularity has declined relative to Kosher chicken breast.  But food and wine and a dance floor do not create history nor they portend a future.  For all the attention on bringing young people into our sanctuary and Hebrew School, attendance and ad book advertising came from the old Adas Kodesch.  It was an expensive evening, perhaps a couple hundred smackeroos for two dinners, an ad, some new clothing perhaps, a trip to the hairdresser, a baby sitter.  This may have detered a lot of the younger ones.   I saw the ghost of AKSE's past but not much of its future.  It that sense, it may have been an error to revel in the past alone.

Physician Posting Sites

My colleagues have opinions, as do I.  We tend to be semipublic figures whose verdict means something, whether or not it is welcome.  Most of us are also dependent upon the good will of our patrons.  The need to enable candor while minimizing unfavorable retaliation for the opinions that we carry has led to a number of web sites that only allow physicians access, to express opinions to each other or ask for medical guidance that can be moved to patient care without formal consultation.  I subscribe to two, Medscape's Physicians Connect and Sermo.  Both are subsidized by some form of advertising, which is good since they would probably collapse if a fee were imposed on the users.  I post on both, but have greatly curtailed my use of Physicians Connect which I think needs to eliminate anonymous posting and obtain a moderator.  For an educated crowd, the physicians can be rather hateful, particularly those raised on revenge in the Middle East.  I do not think a lot of them would want that level of candor identified with them and conveyed to their patients.

Politically, the most dedicated come across as libertarian:  "Mine is mine and yours is yours, Average, though some say this is Sodom"  as the sages of Pirke Avot observed.  Sermo people have pseudonyms of their own choosing but not outright anonymity.  Politeness is valued a good deal more on Sermo than at Physician Connect and remarks belittling another poster are rare, even on the political discussions, at the former though common enough at the latter that I took my intellect elsewhere.

People can also run medical dilemmas and opinions by specialists.  While both contain a few medical loonies promoting their fringe agendas, the regular medical posters on each seem a reasoned bunch.  Still, I get the sense that people who fundamentally like being doctors opt for Sermo, the kvetchers congregate at Physicians Connect.

Veterans Day

South Florida Veterans Cemetery

Dad's Final Resting Place

Beth Tfiloh

There are some destination synagogues for me.  While saying kaddish, I took a liking to the experience and clergy at Beth Emeth, our local Reform congregation.  While initially attracted by the security of a minyan and the convenient time for Kabbalat Shabbat services, it did not take long for me to admire the Hazzan's musical skills and the Rabbi's intellect.  My own religious preferences aside, I always return to my car after a cup of soda at the oneg, about the only thing there I can consume after a fleishig shabbat dinner, thinking I have been to a place of kedusha.  My own congregation does not seem to put holiness among its aspirations.

About once or twice a year, my destination congregation is Beth Tfiloh, a nominally Orthodox gathering in the northern suburbs of Baltimore.  If I leave Wilmington at 8AM I can generally arrive at the end of Shacharit, and have never been disappointed.  Each visit has a Bar Mitzvah, which I utterly loathe at all of the Wilmington congregations, where the boy effectively pre-empts shabbos.  I make a point  not to go those weekends, substituting some Pikuach Nefesh activity like being on call or donating platelets, which is what I was supposed to due yesterday until I botched the prep by taking aspirin from my pill case within 72 hours of the scheduled donation.  So I went to Beth Tfiloh instead.

Beth Tfiloh has a mechitza, which my wife loathes. It is only about four feet high, made of plexiglass with an unobtrusive design. From my seat yesterday, not far from where I usually sit, I did not notice the physical barrier right away, just a lot of women on one side of the sanctuary and a lot of men on my side.

Each time I've been there, they have a Bar Mitzvah.  I'd expect that from a congregation of over a thousand members.  Yet the Bar Mitzvah never seems to intrude on the service.  Twice they had invited guest speakers, Ruth Messinger of the American Jewish World Service last spring and Martin Fletcher the Middle East correspondent for NBC News yesterday.  It would be unthinkable at AKSE or Beth Shalom to ask a Bar Mitzvah family to share their assigned day.  Rabbi Wohlberg always has a presence, even if it is only to introduce the guest.  Who is honored? One who honors others.  Avot 4:1.  The rabbi has had a word of tribute for all he mentions, from the Bar Mitzvah to the woman observing her 100th birthday in absentia.  For an orthodox congregation, he finds a suitable role for women.  I would not be surprised that if in private he is apologetic for not being able to offer more.  This being machar chodesh, the women have a role of gathering for t'hillim or Psalms.  He mentioned a women's tfilah group in passing.  Attendance of 45% women by my estimate speaks for itself.

And there was no amateur hour.  All participants came across as suitably skilled, even the Bar Mitzvah bachur who did a more limited amount of worship than some of the others.  A morning's delight.  Worth the shlep each time I go there.

shabbat prep

Every Friday morning I arise early, or at least on time, to begin shabbat preparation that usually starts   Wednesday by defrosting the meat I plan to cook, defrosting two minichallot on Thursday and preparing the dinner Friday morning.  Chicken breasts work well since they cook easily but beef cubes can be put in a crock pot with vegetables and are ready by sundown.  I usually make a starch, occasionally a vegetable, almost never a dessert.

Gas gets put in the car on Thursday night or Friday morning if there is less than half a tank.  I stop at the cash machine if I have less than $50, though I rarely spend money on shabbos, other than my weekly cup of coffee to help support Sweeney's Bakery around the corner.  When I get to the office, I put half my coins of each value into the pushka on the window sill. 

This year I find myself less observant than last year, something that has cycled over decades.  Sometimes the lapse involves circumstances or choices largely imposed upon me like call schedules or moving to St. Louis to attend medical school.  Sometimes, including now, the reversal makes a statement of my disdain for people promoting their own observance agendas.

I attend synagogue less than I used to on shabbos morning, more on Friday night.  On shabbos afternoon, when I used to rest or read, if not on call, I now schedule an appointment with myself to go out.  I've been to a few arboreta, a nature preserve, some state parks, the beach, and maybe this weekend a college football game.  I think these are the down times from the work week, just as much as steering clear of the cell phone and computer and stores, which I still do.

Election Day

When I started, I had intended a forum for irritated physicians and synagogue members, of which there is no shortage.  I have been ambivalent about whether the intent was to act or to vent.  Polling suggests that dissatisfaction with our social environment extends to many parts of our grand experience.  The voters today, and increasingly by absentee the last few weeks, intend to act.

Sanctuary Ennui

My retired friend spends much of his unscheduled time in the library, sitting at publicly funded screen while searching cyberspace for items of interest to send along to friends who are not retired.  Sidestepping the issue of electronic clutter that this sometimes creates, he hit a home run this week with an op-ed piece from The Forward, America's principal Jewish weekly, regarding the experience of attending services in different locales.   In some ways I may be a modern day Hellenist willing to sacrifice some elements of tradition and letter of the law to enhance beauty or justice, and like most Americans have been acculturated to pluralism by the tenets of our basically irreligious Founding Fathers.  I think Judaism would be better if the law promoted gender equality.  I am less convinced that it is better by adapting the law to reflect that, as most Conservative synagogues have done, though they seem to have paid a very high price for the practice.  Perhaps parity would have been a better goal.  Yes, I am for gender equality and my activities outside AKSE reflect that.  I am also for having Kohanim and Levi'im precede me in Torah honors even if there is a measure of lunacy to having some shoeless Am-Ha-aretz mumbling a bracha that had to be transliterated for him so that he might function as a divine conduit to bless a congregation of lesser yichus but greater accomplishment.

To make the proceedings of the sanctuary less intimidating to the novice we introduce contrivances like responsive readings of inanely translated liturgy.  I think the sermons at AKSE rarely contain content that require anybody to be particularly literate to understand.  Whether the Rabbi intentionally dumbs it down or actually functions at that level of erudition himself can be debated in both directions, I suppose.  Berel Wein in his Tending the Vineyard, his memoirs on life as a congregational Rabbi, noted that each week he only has one real chance of about ten minutes to convey a real message of Judaism to the listeners that will have to sustain then to the next Shabbat morning.  It our effort to be inclusive and not leave people behind, we sometimes forget that the mission of Judaism is to elevate people to a higher standard than from the starting point.  Instead, we have changed the destination without really changing the people.  In the USCJ world, egalitarianism, for all its social merits, ran in parallel with congregational decisions to popularize attendance via expanding comfort zones when they should have been upgrading educational standards.  We elevate people to the mitzvah.  We do not diminish the mitzvah to facilitate compliance.

Quest for Mediocrity

Sometimes the quest is a relentless one.  In both my medical world and my Jewish one this pursuit emreges in a variety of ways.

Having divested myself of all AKSE Committees except Education, last night I undertook my remaining contribution, which includes setting up a night of learning and arranging a visiting scholar, both works in progress.  The committee decided we wanted a woman, as we had never had one, and I decided that we would capitalize on that talent to advance our women who have already reached Mediocrity's Promised Land and share it with the Lotus Eaters who now aspire to nothing else.  I wanted our rising star in the learned observant Jewish world to worship with our women, if only to get them to elevate themselves for the purpose of having the guest think well of them.  The response of the chair was just the opposite, to shield our women from having to move themselves along for any reason.  It does not matter if I was able to bring cutting edge Orthodox Judaism to the Orthodox Pretenders, it disturbs the mission of stable mediocrity.  So does requiring that all programs, without exception, undergo scheduled periodic assessment to determine future upgrades.

Having the seat on the Board of  Governors reserved for laytzanos, I was equally disheartened by the Executive Committee report.  Not only do they think they can make membership grow by dumbing us down and finding the niche gimmicks that portend the destruction of United Synagogue Jewry within the next generation, but they take the erroneous view that advancement should not be forced upon people.  Friday night services are sparsely attended for a variety of reasons.  I find them strikingly unattractive and go elsewhere as a destination at the start of each shabbat.  But I they get ten men and can check the boxes that all prayers were recited, then there is no reason to make the service attractive to anyone else.  If they get nine, there is still no reason to make the service attractive to anyone else, just recruit a tenth and leave things be.

Sometimes the quest for mediocrity is indeed relentless.   

Diverting My Contribution

Each year on Yom Kippur, the congregational president of AKSE makes an appeal for extra funds, which adds about 20K to the synagogue's treasury.  This is the largest fundraiser of each year.  It takes no committees and costs nothing other than the bookeeping and banking costs.  It has been my tradition to write a check for $100, no strings attatched, nothing conditional to the check.  Despite the long precedent, this year the contribution does not go to AKSE but to an organization called Women of the Wall, which our local reform congregation, Beth Emeth, has adopted as their recommended cause.  While I have the good fortune to enjoy sufficient prosperity to write two checks of $100 each, I feel very strongly that this contribution really needs to go from AKSE with me as the conduit.

One of the challenges of observant Judaism has been the ambivalence to what the optimal role for women ought to be.  When our Rabbi came aboard, my wife and I were optimistic that the role for women in the congregation would expand in a meaningful way.   Had the Rabbi opted to take the progress in stages, conduct some experiments and modify what needs to be modified, I would have jumped aboard.  Instead, he made some very trivial decisions that I think reflect a fundamentally limited intellect and marginal gift of Binah from HaShem, the closed the door on further modification citing the authority he has as mara d'atra.  That is not like me at all, where I round on patients every day and correct yesterday's errors as I go.  Judaism as I understand it takes a dim view of victimizing people without recourse.  Our women are doomed to mediocrity without prospect of reversal.  The Women of the Wall still have an upside.  That is where my money goes.  It cannot also go to support impropriety on my own home front.

While I think Derech Eretz would have me simply toss my AKSE pledge card into the recycling bin and write a check to Women of the Wall, my wife put a condition on the diversion.  I would also have to write to the congregational President and explain to him in Jewish terms why the Women of the Wall are of superior worthiness.

Physician Posting Sites

This summer I decided that I would no longer post comments on Medscape's Physician Connect, where I had been a regular for a couple of years, except at the Endocrinology division.  I tried replacing it with Sermo, where I found the physicians more congenial but for the most part these places do not really attract a lot of people whose goal is to be congenial.  Instead of finding it a place to exchange ideas, I found it a place to promote agendas, a place to express the desire for the gimmes whether that be removing the Israelis and any other Jews from Israel or removing the democrats from public positions or removing formularies from insurance so I can have my own way with no interference.  When somebody who a different view somebody will invariably respond that they are inferior in some way.  After maybe a year of this, doing my very best to be both erudite and polite, I found myself adapting to this environment more than I would like and offered myself a hiatus.

At first, I missed having a chance to express myself but that craving ran its course in a week or two.  A few days ago, I gave it another look, reviewing the political discussions on Medscape and the medical ones on Sermo.  I responded to Endocrinology on both but the political and practice of medicine subjects no longer held sufficient interest to open up the discussions to see what the medical discontents had to say about their never ending lists of real and perceived enemies.

Weekend on Call

My first weekend on call at Mercy.  It was definitely a quieter place than Christiana, with four new consults and about eight others who needed some kind of personal attention.  There were not a lot of consultants or even ICU people or surgeons milling around by early afternoon, with the assigned hospitalists and a few residents assuming most of the patient care.  On Saturday afternoon, the hospital hosted a community health fair so I agreed to occupy the ASK A DOCTOR table for about 90 minutes.  A few folks came by including a couple of diabetics who needed some professional attention, but mostly folks with minor events that would not ordinarily incur a medical visit but as long as somebody is there to look at the rash or sore shoulder for free, why not.  A physician who charges nothing is worth nothing (Bava Kama 85a), though that comment comes in the context of just compensation for an injury which includes payment for medical care, which by Talmudic requirement has to be mainstream care.  I must say, I enjoyed being at the table, watching the people go by as I sipped on a Diet Coke.

Then Sunday I did real on call type of work, a slower pace that enabled me to think about what I was doing, instead of the Christiana burden of just getting through the enormous census and unending cell phone interruptions.  Definitely a more civilized experience, and I suspect a lot better for the patients to have a doctor who is thinking more about them than about the tasks that lie ahead.

Electronic Medical Record

My first day in Mercy's outpatient Endocrine Office, saved by no-shows which enabled me to struggle with their electronic medical record, a system called Nextgen.  Our financial institutions and travel systems have taken full advantage of computerization, though our medical systems have been laggards.  While I think there is much to be gained, the systems that I have encountered do not seem to be able to template a complex present illness such as diabetes particularly well.  One worthy project might be to compare dictated History of Present Illnesses with those templated.

Mens Club Discussion

AKSE has both a Mens Club and a Sisterhood, each productive in its own way.  The Sisterhood raises money and makes sure food is on the table for kiddush and other events.  The Mens Club meets monthly with some type of program.  I attended today's meeting, one that I had looked forward to, where a U of Delaware professor of Jewish Studies would present on how he transformed from a good ol' boy of non-Jewish ancestry to a Jewish scholar, who definitely did not attend Rabbinical Junior College.  Despite my anticipation, and the obvious knowledge of the professor, the morning was a great disappointment, so much so that I looked at my watch and bentsched early as the Rabbi watched. 

The talk just wasn't focused.  To make it more arduous, the organizers invited the Jewish War Veterans to present.  And furthermore, the food fell short of its usual attractiveness.  I probably won't go back to any more of these, no matter who is scheduled for the presentation.

High Holy Day Sermons

Survived another Rosh Hashana and Yom Kippur, not quite knowing where I am sealed.  Didn't do so great on "latznu" from the viduy, and not about to take the Rabbi's advice to work on where I personally fit in on my transgressions, at least that one.

I do not recall what the Rosh Hashana sermons were.  Something about binding Yitzchak the first day, even though they didn't actually do it until the second day.  For the second day, my daughter commented something about Dr. Phil on the pulpit.  I do not recall anything of the sermon only the paucity of Jewish content, decent theme probably but without the substance that would enable me to recall the content a week later.  Yom Kippur went better, with the Kol Nidre message including a decent review of several passages of Al Chait and a poignant message introducing Yizkor based on his feelings following his experience with a stillborn child.

Last night at AKSE's Board Meeting we had a High Holiday review.  To my great surprise the sermons were well received by most of the Board Members.  None of them required attendance at Rabbi School, the Jewish content was paltry in all, though compensated by other things in the YK messages.

Patient Repairman

My new job has commenced.  While I learn the lay of the land, I started seeing consults and visiting the primary care settings from which my patient originate.  Thus far, the consults have challenged me, which energizes me more than I have been in some time.  Not that I want anyone to be unnecessarily ill or ignore prevention but working as a repairman brings a type of thrill that had been dormant.  Most of the people that I've seen had little medical thought given to them by those who had been treating them.  A few easily correctable insulin revisions make all the difference the first 24 hours, though I ask each of these folks to bear with me for about six months to reconstruct their diabetes from insulin to end organs.  Some of the people seem a little surprised to learn that with some alterations of treatment, they could be doing better.  People had been experiencing marginal diabetic care for more than a decade, yet I was the first endocrinologist they had seen.

Can Obamacare really improve the medical outcome of these individuals?  Unlikely, as absence of insurance does not seem at first glance to be the barrier to lower glucoses or protection of body parts in the diabetics that have come my way the first week.  I think there needs to be somebody accountable for optimal medical decisions.  As I visit the primary offices in a three mile radius, I do not perceive a lot of attentive goal focused medical care, with a few exceptions that bring me a measure of optimism.

For now, I like getting up early to go to work.

New Year 5771

Rosh Hashana eases in and eases out.  The day clearly demarcates one calendar year from another but it really occurs at about the midpoint of a season.  At the start of Elul the parochet and Torah mantles switch over to white, Avinu Malkeinu, LDavid Hashem Ori and Shofar begin and continue through Yom Kippur, with an extension for Psalm 27 through Shmini Atzeret.   Unlike the American New Year which tends to function as the anticlimax to the more widely celebrated Christmas, the Rosh Hashana goes in the other direction beginning an upward swing to Yom Kippur with sukkot as the anticlimax, though preserved by the comeraderie of socializing in different people's sukkahs.

At AKSE the first day appeared well attended, the second day less so.  I located the No Chatter Section for the first time, staying in the designated Men's Section the first day.  Unimpressed with sermons which had vallid topics but paltry Jewish related development.  Went to in-laws afternoon of first day, followed by tashlich at nearby stream that still supports minnows who enjoyed the bread fragments.  After yontiff, shabbos, appropriately restful, then some light chores Sunday, then new job Monday.

Definitely a transition of one time to another.

Erev Rosh Hashana 5771

My greetings have been pretty much sent.  This morning I arose at 5:30, my last full day in my medical office, to prepare dinner for yontiff.  Irene made her annual rice kugel last night.  I made the chicken today.  I was going to make honey cake and had all the ingredients out but took advantage of my New Year's intent of cutting down on procrastination by postponing this until tomorrow, to take to my in-laws.  I made Kojel for dessert instead.  It goes much faster but never gels as well as trafe Jell-o, though I am told that there is now a reasonably competitive Kosher product.

Rozzy plans to be with us for the holiday so we purchased a worship ticket for her.  I picked out a Round Challah, initially getting an Ace product from Safeway but returning it to the shelf when the self-register rang up $9.59.  Procrastinate next year, try not to.  Cheap next year, you betcha.  Got a smaller and less inviting one at Shop-Rite for less than half that.  Tablecloth looks grungy and I could not find the other fleishig one, so probably stop off at Boscov's on the way home for a new one.  Then make a vegetable, make the soup and heat up the pre-made stuff for a good start to the New Year. 

Son's birthday tomorrow.  Same birthday as the world, at least this year.

AKSE Ad Book

Some background: Adas Kodesch Shel Emeth, my congregation since 1997, needs to raise money or to spend less. About every five years they sponsor an event to celebrate something, this time the congregation's 125th anniversary. While it may be a social bonding success, though a very transient one, it rarely makes a lot of money as up-front costs of dinner and publicity are high. The Board and organizers always seem very ambivalent as to whether the purpose of the effort is social or financial. The dinner breaks even, though if they replaced the live band with a DJ they might come out ahead. I'd expect people old enough to have hosted some family simchas to possess the saichel to realize this. In any case, the real fundraising comes from an ad book, for which Irene and I wrote a check for $118 for a half page to announce a message. I could not help be a laytz, extracting the four types of students from Pirke Avot [5:15].

There are four types among those who sit before the sages: the sponge, the funnel, the strainer and the sieve.

The sponge absorbs all

The funnel takes in at one end and lets it out the other

The strainer rejects the wine and retains the sediment.

The sieve rejects the coarse flour and retains the fine flour

Labor Day

HAPPY LABOR DAY

UAW

Push

Labor Party

Hard Labor

Rosh Hashana Week

Some transitions.  Kids start the new school year, some heading off to college for the first time.  I tie up loose ends in the office in anticipation of my new job about a week hence.  And then we have the transfer of the calendar from 5710 to 5711.  I've been writing my summary of the past year: loss of father, closure of medical office, new car of necessity, new blog induced by some friction at synagogue, reunion with friends not seen in a while and likely never to be seen again.  Much to bore other lost friends if I neglect to edit the grand message for each individual recipient.

Selichot at AKSE last night.  Rather mundane discussion of the expected topics, the successess and failures of the year gone by and how we will ask Lucy to hold the football so we may all kick it one more time to allow ourselves the score next time that eluded us last time.  As a college kid, I used to took with anticipation to selichot, particularly if Rosh Hashana occured shortly after arrival on campus.  It was my first chance to socialize with friends who had made themselves scarce the previous two months, and without the threat of exams or frat parties competing for attention in Sunday morning's wee hours or an alarm clock jolting us at sunrise.

Rosh Hashana week has some acquired predictability nowadays.  My son's birthday preparation, some Torah reading to be done, a Haftarah on Shabbat Shuva, special menus and meals to be arranged, office coverage to be confirmed and an afternoon and evening with my in-laws.  Then a one day breather, then a new professional venue to make the transition an ongoing one.

Shabbat Prep

End of the work week, end of the summer.  Very early on Friday morning with a few tasks separating me from a shabbat respite, or if not a respite, then a change of pace.  I made the foundation of dinner:  flanken and Israeli couscous with sauteed onions and mushrooms.  Then some cauliflower to parboil before lichtbentschen.  When I get to the office, I will put my coins in the Pushka, then bring the pushka to my car, as this is the final Friday that I expect to be in my office.  Maybe I will empty the Pushka, put the coins in the TD Bank coin counter and write a check for the proceeds to the Hebrew school like I usually do at the start of their school year.  It will probably be the final tzedakah check from my office account.

On Fridays I do a double portion with my Franklin Planner, outlining both Friday and Saturday anticipated tasks.  I also think about where I will attend services, usually Beth Emeth for Kabbalat Shabbat and AKSE on Shabbat Morning.  This week I also need to pick up some mini-challot, either from Trader Joe's or Safeway.  Come the end of the workday, the tasks will close, the majority typically not done, to be half-heartedly restarted when the sun goes down Saturday and more vigorously shortly after sunrise on Sunday.

While shabbos is different, is it really better, as people tell me it should be?  Definitely a difficult question to analyze, but for now I'm content just leaving it different.

Electronic Outpatient Records

This week I completed my formal training on how to enter data on Endocrine outpatients at Mercy Catholic Medical Center where they are implementing an electronic record, to begin on my second day on the job.  Over the years I have become something of a medical craftsman, not quite an artist who takes creative liberty, but somebody very proficient who can discern one person's situation from the next.  It came as a shock to encounter a computer program that can be clicked in minutes and generate a relatively nonspecific narrative about diabetes.  It reminded me a lot of my residency time of despair when assigned to the coronary unit.  I quipped in the 1970's about templating everyone's history with substernal chest pain of x hours duration that radiated somewhere, as where usually didn't matter much unless straight through to the back where thoracic aortic dissections go.  You enter the age and the response to nitro if any and you could save yourself a good deal of writing.  These histories didn't matter much since everybody got templated in their care with cardiac enzymes and an ekg.  The differences in the ekg's mattered as did evidence of congestive failure but for the most part a jaded resident like myself could safely conclude that most angina follows a pattern that leads to uniform lab testing and a small variation in decisions with little nuances of history not all that essential to decisions.

That is not the case for diabetes where the difference between me taking care of it and the primary physicians or non-physicians taking care of it are the nuances of history.  There are responses to individual medications, as virtually everybody who comes for consultation arrives already unsuccessfully treated.  There are end organ symptoms that belong in the HPI, not the ROS.  It is extremely hard to template that but people try.

Synagogue Governance

Do I really care about how AKSE or any other synagogue is run?  Should I?  Having been to a place where I'd classify some of the activity of the baalebatim as bordering on evil, I think there is a reason to not only remain in the game, if possible, but to give up and depart under certain circumstances.  It seems that trends in membership data may support this view.  Fortunately there is nothing evil about AKSE.  Dumb, inept, insufficiently thoughtful for sure but not evil.

We have a Board Meeting tonight with the usual subjects up for discussion, mostly money either directly through a budget presentation or indirectly through a membership discussion or fundraising efforts that probably would do better if run by newcomers who did not carry the legacy of previously marginal efforts.  But directly or indirectly the agenda is money.  At least these things are measurable.

The real essence of how a congregation serves the people who attend, or who pay dues but don't attend, can be more elusive in its assessment.

Semi-productive

Quiet shabbos, intent to do chores on Sunday partly successful.  I made progress with making the bedroom tidy, washed the dishes, did grocery shopping, worked on my Torah portion, opened some unopened mail since last spring, listened to a yutorah.org shiur, took Alan to the bus stop and replaced my fleishig skillet that had served me well since my wedding but has acquired a significant part that fails to heat adequately.  Not bad. 

Shabbos Prep

Each Friday morning I arise at the appointed time, even when I wish to sleep longer and probably could sleep longer with no adverse work consequences.  My task: have a suitable shabbat dinner assembled before leaving for work.  Usually I make something simple, most typically chicken breasts seasoned, though sometimes cut-up chicken.  The best buy is actually whole frozen chicken but that has to be thawed earlier in the week and roasted the night before, as does turkey breast with bone in, as turkey cutlets are not freqently in the Shop-Rite case.  From time to time I will place beef cubes or chicken parts in the crock pot along with things to eat with it, a one pot meal that lasts several meals.  I usually make a starch serving, typically a box of couscous that cooks in minutes or rice variant that can cook while the chicken is in the oven.  Mini-challot are obtained that morning or defrosted the night before.  A vegetable or salad is made when Irene gets home, or in the winter a vegetable is made that morning and reheated on arrival home.  I rarely make dessert or buy dessert in advance.  Soda and beer are put in the refrigerator that morning. 

While I rarely spend money on shabbos other than a weekly cup of coffee early Saturday mornings at Sweeney's around the corner, more to support them than real need for outside coffee, I will also make sure that I have $50 available to me in cash and at least a half-tank of gas if I want to visit someplace that I might not be able to do on days when I have chores.  Half of each type of coin is placed in my Pushka when I get to the office, with the other half going to the Pushkas at AKSE during the repetition of the Amidah at Sunday morning minyan.  I read a commentary on the weekly parsha, usually one from the Rabbi I've chosen to follow each year.  This year it is Rabbi Wein.

Time has its own sanctity, as do the core concepts of Judaism including shabbat, synagogue and community.  None of them performs optimally.  All have their compromises.  All need tweaking, despite ongoing resistance to being tweaked.

Filling in the Calendar

Last night I returned home from AKSE's Education Committee very disheartened.  My cohorts at the meeting had no interest in anything innovative, provocative, stimulating.  They had slots on the calendar to fill in and they did it.  Most AKSE activities strike me that way, from Shabbat services to Board Meetings.  I tried to make Minyanaires different with random discussions that people could not get anyplace else but for the most part the mentality is one of let's reconstruct last year's programs, get the same Torah readers to do what they did before, never risk negative feedback, and get a different result than the last time we did the same thing.  There are very few really stimulating analytical people there.  People don't like to move the furniture around and see if the next configuration comes out better than the last.  I suspect that the 125th Anniversary fundraiser will mimic the 120th with the same result, or perhaps a small profit though not one to impact materially on finances.  Board Members taking out $100 ads while the business that they work for that have $300 as chump change will be left to languish.  We populate our membership rolls with decent folk who go to work, do what they are told, have their periodic salary deposited but never have accountability for innovation, adaptation or risk.  We populate our committees, Board and pews the same way.  The slots on the calendar get filled in so that events happen at the appointed time.  Better events?  More inspiring events?Not yet.

Physicians of Despair

The Annals of Internal Medicine released a summary by Zeke Emanuel et. al. of how the upcoming health care law will impact individual physicians.  First, I had the privilege of attending an invited talk by Zeke at the Leonard Davis Institute last November and the added treat of having him answer my question.  All stereotypes that his public statements have created of him, he is a very astute, articulate thinker with real medical experience.  The bottom line seems to be that for service to patients to become maximally effective and efficient, medical care will need to achieve electronic computerized parity with the banks, hotels, airlines and pretty much any other industry.  I've had my billing system computerized via a service since the late 1990's, as have most of my colleagues.  I do not even know if traditional One-Write Billing stationery is still available for purchase.  Patient care, however, still depends on written charts, though the large hospitals seem to be making progress in transforming to electronic record keeping which enables access to specific information more readily, as long as the doctor knows what needs to be retrieved.  To do this requires a large capital infusion with little financial return, since payment currently depends on how many patients you see or procedures you do, which will remain the same.  To address this newly mandated overhead, economy of scale will predictably be required, with a fairly safe prediction that physicians who practice alone or with a partner or two will need to seek employment, as I have already done.

For many of us, we value our autonomy above all else and found medical careers one of the few remaining outlets for continuing that.  Self-employment as we think of it will soon disappear and with it the freedom to hire who we want, set our vacation schedule, keep a share of our profits for extra work, and maybe even give us a means of product differentiation of why patients should come to our office rather than a colleague's.  Sermo, a physicians web site, printed the article and invited members to comment, which they did.  People post with considerable frequency that they are fed up and often professionally threatened.  The folks in their 30's and 40's will have little choice but to adapt and maybe withhold tuition from their kids if they express an interest in studying medicine.  The people my age are more likely to have their financial advisers total up their assets and if financially feasible call it a career.  There is clearly a sense of loss, an early expression of mourning for loss of what we once had.