Friday, December 31, 2010

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.

Thursday, December 30, 2010

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.

Sunday, December 26, 2010

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.

Saturday, December 25, 2010

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.

Friday, December 24, 2010

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.

Tuesday, December 21, 2010

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.

Thursday, December 16, 2010

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.

Monday, December 13, 2010

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.

Friday, December 10, 2010

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?

Thursday, December 9, 2010

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.

Friday, December 3, 2010

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.

Thursday, December 2, 2010


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.