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.