Monday, September 16, 2013

YK Reflections

Our holiest day came and went.  Kol Nidre was not particularly well attended.  The sanctuary seemed more completely occupied the following day, keeping in mind that the portion devoted to seating has been reduced every few years.  We were asked for money a lot.  Mostly noble causes like keeping the synagogue solvent or supporting the infrastructure of Israel.  The reason for buying Israel Bonds was a lot more obvious than the reason for keeping the synagogue solvent.  One of the salient features that keeps AKSE different from Chabad is that AKSE has to adapt to its constituents while Chabad does not.  Keeping it solvent for the sake of keeping it solvent without keeping it attractive and vibrant as a consequence of keeping it financially viable might be a hard sell.  And there was a pitch for pet projects:  AIPAC,CUFI, multicongregational Israeli trip which seems unduly expensive, parsha class.  None of this really grabs me, though I do plan to study the parsha each week on, something I've not done in a few years.  Maybe Israel has become the new Holocaust, a purpose for existence beaten into a cliche by Hebrew School or Rabbis who want to turn their congregations into Hebrew School.  Of course it has its place, but so does the Parsha and so does the reality that CUFI while friendly to Israel also carries the banner of some very un-Jewish ideology that gets hidden, perhaps even a form of genevas da-as.  But throughout the YK observance, somebody on the bimah was trying to sell us something.  It all registered neutral, which is better than registering negative.

In my capacity as observer, there were some encouraging parts of the experience.  People of great talent occupied those seats, most of them capable of doing a lot more to enhance the congregation than they currently do.  Perhaps they would if anyone solicited their participation but for the most part nobody has.  If there is any legacy to the outgoing President, who has really worked hard on the congregation's behalf, I think it is that he surrounded himself with a small group of insiders that he knew he could work at the expense of creating a grass roots.  The role of committees has contracted, contrary to the advice of the consultant a few years back.  Appointments for key initiatives comes from an ever contracting pool.  The Nominating Committee has been thoroughly corrupted from a means of evaluating and expanding talent to a telephone squad for the President to decide who he wants to surround himself with.  That form of thinking has some very negative consequences for an organization that has thrived on its openness, some of which seem to be playing out.

And finally, the break the fast presentation was superb.  In addition to an outstanding display of food, they took advantage of a diminishing attendance to create a space with tables behind the sanctuary where people could help themselves to food and enjoy each other.  The people really are capable of excellence but sometimes you have to insist that excellence be consistent in all activities.

Wednesday, September 11, 2013

Opting Out

My third and final ACP renewal notice came in the mail yesterday, still unopened.  While the ACP remains the medical organization for which I hold the greatest fondness, I decided last spring to let the clock run out on the membership without renewal.  The reasons are multiple, reflecting on a mixture of the organization and of me.  I'm in the middle of reading a well considered book called Relational Judaism by Prof. Ron Wolfson who I've met a few times.  He describes the atrophy of once strong Jewish organizations which now struggle, partly through no fault of their own but partly through decisions of how the leadership and policy makers related to constituents.  It is very easy to look at synagogue membership or ACP membership as a consumer purchase.  In one sense, the rather high fee is of secondary importance since my hospital pays for one membership a year.  I could ask them to pay $600 to the ACP instead of half that to the Endocrine Society but my professional attachment has clearly evolved with the specialty.  But as a consumer purchase you have to assess what is received and set a value on it.  It's probably better for medical organizations or Jewish organizations to promote relationships, as Ron suggests in his book, than to sell a product that is often difficult to define.  I've not read an Annals article in a few years, attended a local or national meeting in a few years, bought insurance or studied from the MKSAP in some time, while the products have always been top notch and the people very gracious when I have attended.

No, it is not a purchase but an assessment of personal and organizational values that are always in evolution, sometimes for the better, sometimes not.  I think I became a continuous member circa 1982.  That leaves about 30 years of experience and transition.  There was a time when Masters got their designation by becoming the people who advanced medicine.  Some undoubtedly still do, though increasingly the designation reflects loyalty to the organization more than the gurus of clinical studies who transform out ability to function professionally.  That can only be a reflection of how the leadership of the organization assesses its purpose.

In 2011, I took what I hope will be my final recertification exam, especially if they decide to do drug screening on illicit Namenda which I will probably need to protect memory at age 70 ten years from now.  To be fair to the ABIM, the experience this time around seemed pretty decent, though cumbersome, unlike 1991 and 2001 when it was more of a fraternity hazing.  I think some of that credit goes to ACP alum, Dr. Cassells.  But the reality is that while my scores are comfortably above threshold, there is an endocrine failure rate of about 12% whose professional lives are disrupted while they remain worthy and competent colleagues.  More recently, the ABIM has made the MOC process more burdensome with little benefit to the public.  This seems like an obvious place where the ACP dropped the ball as the advocate of its members and no particular incentive to cap this type of regulatory excess.

Over that same 30 years the role of the internal medicine specialist has become more amorphous under the ACP's organizational watch.  There are places in our State of Delaware where a Board Certified, fully trained ACP Fellow can request expert consultation and have their patient assessed primarily by a nurse practitioner in lieu of the expert they were hoping to capture.  Not only has the ACP never challenged this but now they have taken a position of boosting membership by absorbing professionals of lesser training into the organization.  This, of course, never came up three decades back but sometimes the physician advocacy organization has a lot more credibility if they put expediency on the back burner and take a stand for consistency with the values that I think most physicians have.

And as Ron writes, it's about relationships.  Would I approach a large check as a contribution for noble cause rather than a purchase if the cause was really noble and if I had a fair amount of skin in the game?  Jewish organization and to a lesser extent medical ones design programs hoping that people will come.  I've designed my share for Adas Kodesch in recent years, some highly well attended.  But are they successful?  If attendance is the goal, then sure they are.  If developing an enduring attachment that withstands strained times and invites a measure of forgiveness for policies that do no go your way, then no, programming does not cement relationships.  In my decades as an ACP member and later a fellow, I was only invited to two meaningful projects the entire time.  Both involved my skill, by the way.  One was to create a wallet card with essential patient information that they could bring to office visits, the other was to attend a national meeting in Philadelphia to critique how the organization could be more responsive to its dwindling subspecialist members.   Total time spend on meaningful projects about eight days.  Never been invited to a standing committee all that time.  Never invited to share my expertise or experience at a meeting, never been invited to suggest an expert to share their special ability with the group.  These are the things that generate loyalty which transcends personal experience that will inevitably have its favorable and unfavorable times.  I do not know if ACP has as part of its mission to bring people on the sidelines into the group, hear their stories, fill in some of the voids that are inevitably part of professional life.  There have been a lot of Governors and a lot of projects in thirty years.  My guess is that the Pareto Principle where 80% of the activity is generated by 20% of the people prevails in the ACP as in anyplace else.  The question is whether the leadership ever thought seriously about how to change the proportion to 70/30 or whether they have the same complacency with A-lists that my synagogue does.

I eventually opened the final invoice letter. sending back the invoice unpaid with a note wishing the organization continued success.  The ACP has always had dedicated well meaning people at its helm.  But they may need to pause to reassess what their own constituents desire from affiliation and a fair amount of financial commitment, then provide it.