Tuesday, October 29, 2013

Break from Sermo

While work can seem something of a pageant with doctors of various specialties and assorted training levels, nursing staff, secretarial staff, management and maintenance, sometimes an escape to a different collection of peers adds to the satisfaction.  A number of online services have created communities of physicians to which I subscribe to two.  Sermo has become a daily destination, a mosaic of specialty mavens, people passionate about their politics even when at the fringes of morality, downtrodden types tilting at the insurance company or government windmills, and handful of bon vivants in a relentless quest for their finest personal indulgence.  My community in cyberspace.  I have created my own niche there, a hormone maven, a prototypical Jewish voter and devotee of Jewish culture and practice.  I'm very much part of the group, a group that I really do not have any place else.  And while the Pirke Avot aphorisms of Hillel conclude with Al Tifrosh Min Ha-Tzibur or Do Not Separate Yourself from the Community, the attachment sometimes crosses the line between sincere fondness and less healthy addiction.

So it is, I made a decision to take my leave for two weeks, starting yesterday.  The first day was not easy, as I had posted a comment on gun control to which colleagues who derive pleasure from shooting a mallard out of the sky took exception.  There are nine more comments that I have not read and probably will not read, at least until my return.  My Google Chrome home page includes  instant links to Sermo, Comcast, Facebook, furrydoc, and Medscape.  Work disallows entry to Facebook leaving me with checking my personal e-mail as the surrogate for not accessing Sermo during the periodic slack times on not so slack times when I feel I might have something important to contribute.  I've never timed how much time I spend there.  Some of it undoubtedly classifies as legitimate work.  When I host residents or medical students on elective, I invariably use some of the other people's posts on endocrine topics for teaching.  My own contributions answering other people's endocrine queries or bantering different medical thoughts with some very learned colleagues of different perspective adds to my own skill so that would justify paying me for the interactive time as well.  And I've asked guidance on my own cases that seem off the beaten path.  I've never neglected my own professional tasks to make political or cultural statements in cyberspace, though perhaps I could have been doing some billing or record keeping or keeping my desk more tidy during those slack moments which never amount to more than ten or fifteen minutes at a time, unless using the service for real professional activity..

So Day 1, resist temptation to click the icon.  Almost there.  Next step, do something else with that time.  Since they are all nearly all brief moments of time, a form of ADHD heaven perhaps, what else might I do with ten minutes instead.  My really big projects, it turns out, generally require much larger concentrations than I give to Sermo.  But there are charts that can be signed, maybe some hospital bills that can be generated, a more orderly desktop created and maintained.  As satisfying as connecting to my professional colleagues has been, there is an opportunity cost, one that is small but real.  It will be interesting to reflect back in two weeks and see what I actually did instead.

Sunday, October 27, 2013


Why have the mainstream Jewish organizations spiraled downward during my adult lifetime?  That's been my exploration while I put my own principal organizational attachment, the synagogue to which I pay an exorbitant fee to belong, on the back burner for the second half of this calendar year.  I've now read pretty much what I plan to read on this and take Ron Wolfson's advice to tell my story.  We each have our story.  For every patient encounter I start by soliciting theirs, either verbally of by review of records or more typically a combination.  If I am successful as a physician, the ability and the obligation to connect with those multitudes of tales has enabled that.

So I'll start with two vignettes, same theme but fifty years apart.  The first took place as a camper at Ramah in Wingdale,NY the first year it was opened.  The grand poobah's of Conservative Judaism put a lot of effort into this, creating a living Jewish environment, deluding themselves into thinking our evolving language capacity will enable reasonable facility with conversational Hebrew, all to attract their most promising students, the people that their crystal balls told them would propel Conservative Judaism into the next generation as a vibrant and enduring branch of American Jewish ideology.  At the conclusion of the summer, the head counselor assembled all the campers to offer his final charge to the departing crew.  Few remarks remain with me for half a century but he indicated that the dozen or so kids who got homesick or did not have a good enough time to tough it out and left early were not real Ramah caliber campers.  They were inferior in some way, not the leaders that the camp sought to develop.  Well, it turns out that I did not have an Ace time there either but toughed it out partly for lack  of a better alternative and not wanting my parents to experience financial loss.  But I made it clear to them and to my Rabbi who was very much attached to the Ramah program, that I would not be going back.  Most of our congregational children had a similar experience and similar response.  While they tried to negotiate with me the option of waiving the camp's rules and allowing my attendance at a site other than the one determined by my home town, I would want no part of chancing that type of summer again.  And of course the assumption was that there is something wrong with me for not appreciating what was offered to me, irrespective of my assessment of the actual experience.

We fast forward to the most recent High Holiday where I encountered the same thought process transposed to a different situation.  Again, amid attrition threatening existence, the treasurer appealed to the congregation for voluntary supplement to dues, including in his remarks that the people who remained were the worthy members.  Anyone who preferred something else or even nothing had to be less worthy in some way.  Not, let's become more adaptive but let's get more money so we can do more of the same for the people who really deserve it.

In between, there have been no shortage of similar messages.  How can you snub a communal leader?   I found the experience with him or her vile, that's how.  How can you not give to Federation's SuperSunday campaign?  Like the other 18% who decline, I had an adverse experience with the leadership or the funded agencies.  There must be something inferior about me if I walk away from irritating Aliyah Sound Bites and find the congregational leadership too inbred.  It takes a while but eventually this Leadership Development Cloning Experiment yields its results.  They are left with worthy loyalists who tell each other how wonderful they all are while the human chaff floats around someplace else in the Jewish environment, adding to its entropy.

Tuesday, October 15, 2013


Haven't written about medicine in a while.  My quality scores got tabulated.  I looked at everyone's feet if they have diabetes and everyone's blood pressure got taken.  My Too High Hemoglobin A1c measure exceeded goals which doesn't surprise me since people are sent because their diabetes has been poorly controlled despite previous physicians' attempts to control it.  What they could not tell me is whether those numbers reflect my treatment or the treatment of the prior prescriber whose handiwork I inherited.   It makes a difference since my annual bonus is tied in some way to the effectiveness of my work though I may be economically victimized by my own willingness to take on some of the most intractable diabetic circumstances around and have high HbA1c scores assigned to my care before I've made my first medical decision.  The Management could not tell me how this assessment of lab results is assembled.  I did very poorly on smoking cessation measures.  Not because I encourage people to smoke or neglect the reminder that they quit.  There is a box that indicates whether you discussed it?  Absolutely checked YES.  Was it completed?  Of course not, they are still smoking?  However the right answer is also YES because the intent of the question was whether the discussion was completed.  So my scores on that are low, not having figured this out until a few months before Son of NextGen became our Electronic Record that I still do not know how to navigate on this four months after implementation.  And finally there is the requirement that a plan be created for every obese patient on every visit.  Nearly all my diabetics are obese.  They are not sent to lose weight but to reduce their glucoses so they are not both obese and hyperglycemic at the same time.  Insulin makes them heavier.  I have no means of changing how insulin works in storing nutrients.  And if there were effective measures of slimming people down short of having a surgeon reduce the efficiency of their innards, we would have been doing that decades ago.

Yet in the tradition of a Milgram Experiment, Obamacare has a provision for requiring the medically ineffective, and sometimes even the inane, and people in authority follow suit with little question on how this jives with the realities of medicine and even nature.  Now, somebody is willing to pay the hospital and ultimately me a premium for doing stuff like this so if they tell me how and it does not deter effective and justified medical care I'm perfectly willing to shake a few extra shekels from the Medicare Trust Fund too.

Monday, October 7, 2013

Tapping Resources

As we transition from summer to fall, and the calendar moves to October, I reach the midpoint of my semiannual projects and the midpoint of my time on AKSE's Do Not Call List.  The six projects could have been further along by now but I regard myself as rather successful in exploring alternatives to a generally mediocre synagogue experience that resembles Hebrew School a lot more than it resembles college Hillel, the principal encounter that really cemented me to Judaism.  Hillel has transformed itself organizationally in the decades since I graduated.  Rather than providing a building for interested people to enter, they have become more assertive about sending shelichim around the campus, identifying friends and friends of friends who might benefit from participating in the programs, then inviting them to be absorbed into the group.  I will assume that the learning and worship that goes on there, at least at the larger places, has stayed at university standard in parallel with other university offerings.

Hebrew schools struggle, the one at AKSE becoming more suitable for a one-room schoolhouse than a multi-teacher enterprise.  Membership at synagogues is down.  I almost ration my own attendance to two shabbatot a month, that being my temperamental limit of Aliyah Sound Bites and Hebrew School facsimile, though it might be different if it were as welcoming as my hospital has been.  Yet as I explore Rabbi Schwarz Jewish Megatrends and Ron Wolfson's Relational Judaism and now Hayim  Herrings Tomorrow's Synagogues Today, I know there are better experiences to be generated and people on the sidelines willing to put forth the effort to generate them.  Accessing them without offending the people in place who indeed do a lot of work and think they are accomplishing more than they really are takes a blend of tenacity and finesse.  I'm good at tenacity.  Maybe the place needs a Cruise Director, that individual who assumes the responsibility for making sure that there are no spectators for the Line Dance.  It's one thing to have activities, quite another to want to be part of the pageant.  It is doable but it means thinking differently.

One approach might be that of IKAR a transdenominational enterprise in Los Angeles.  Everyone can come and watch but you cannot become a member unless you commit to some activity to engage in.  AKSE could do that up to a point and would be better off with tapping into talent as a requirement instead of depending on A-list invitations from the President.  Maybe my project would be to catalog talent, if I end up wanting a project.  Talent exists but it stands with me on the sidelines, either for not being asked or for being former talent that got slighted in some way.  Some upcoming chat with the visiting scholar next month.