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Sunday, December 9, 2018

Road Trip



Despite being of age I missed out on much of what the 1970's offered its 20-somethings.  Not that there's anything amiss about studying chemistry in college, proceeding to medical school and residency, or getting married, the achievements that shaped me favorably forever.  But some experiences of the times did not happen and do not recapture easily.  Too little prosperity at the time, too much now, or at least too many obligations.

Image result for road tripIn that era, people used to go on wild spring breaks to Daytona Beach, but it would be unthinkable to spend my father's money that way.  My own kids mostly agree.  I could have done a medical school elective in Alaska or the Nebraska prairie but didn't, opting instead for six weeks of anesthesiology in Philadelphia on a grant that funded my fiance's engagement ring.  And people backpacked in European hostels, did a semester in Israel, or found somebody with a VW Bus redone with a psychedelic exterior to journey coast to coast via roads other than the Interstate.  I never did any of those things, not then, not now.  Made it to Israel as a tourist for my 25th anniversary and to Europe for my 40th, no serious money limitations but no extravagance either.  And the itinerary was a lot more secure and a lot less flexible than for my contemporaries to headed off to whatever they might find as 20-somethings.

One my home from Europe a few months back, the jet's entertainment module offered a feature on those 1970's travels that other people took.  As well as things turned out for me personally, missing out on that borders on a regret.  Now that I am retired, I theoretically could.  In fact, my father, a relative newlywed and newly retired person of about my age did exactly that, taking his time with my stepmother to traverse the country from Florida to Los Angeles over six weeks.  My own life still has fixed obligations, though.  A cat that needs care, but at least in theory could travel.  We take university courses.  My wife participates in musical activities.  Six weeks on the road cannot happen.  Ten days on the road, just myself if need be, could, limited by my own willingness to proceed.  But as a 60-something, and a highly accomplished one, my life has become a series of predetermined destinations to pursue, which no doubt accounts for what has been accomplished.  The GPS is set to take me someplace and I know when I have arrived.  Driving in a direction but without an end point to mark arrival doesn't really register in minds like mine. 

The video on the plane tempted me, though.  I should make an effort to see what roads are there without setting the GPS first.

Thursday, December 6, 2018

CME Inventory

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Pennsylvania medical licenses expire at the end of each even numbered year.  If you do not engage in heinous acts, most physicians just get processed through by some clerk near Harrisburg, the state capital, making sure that all the boxes are checked off and that the credit card payment goes through.  A sample gets audited, but that has never been me, not in Delaware, Massachusetts, or Pennsylvania where I have held licenses at one time or another.  Most of us are pretty good citizens and professionals that do not cause a lot of trouble. 

There are some very specific requirements above having a valid credit card and having the professional training that you claim.  The most intrusive is the Continuing Education standards, which are not difficult for us city folk, maybe a little harder for those taking care of people in rural Pennsylvania.  Every two years we need to show attendance at 100 hours of training, 40 of which need to be certified as Category I.  I just take the New England Journal article review courses, good for 50 credits per session.  Unlike showing up and sleeping through Grand Rounds, which most large institutions offer for free credit weekly or attending a national specialty meeting that would accrue 20 or so credits but at a high fee, the NEJM and most on-line courses care a little more about your learning something from the effort so they require a test of what was taught.  Not a big problem at all, and keeps me better engaged.  So I have my 100 credits, all Category 1.

As a practicing physician at the VA, I needed a license from any state, so I just continued my Massachusetts license.  The Board there can be a mixture of pompous and ornery.  They introduced a requirement in my early practice years that you needed 12 hours among the 100 related to risk management which could be defined rather broadly, but it was Category 1, the most difficult to acquire.  I did it, got a Delaware license, let the Massachusetts one lapse, and eventually took a position in Philadelphia for which I got a Pennsylvania license.  Initially they did not have this requirement, and I was in a training program which waives the CME anyway.  On returning to Delaware, I eventually let the Pennsylvania license expire, more for escalating costs than renewal requirements, but reactivated it when I started working in Philadelphia again, now with roughly the same 12 hour risk management requirement, though not limited to Category 1.  What qualifies has always been a little uncertain but as we get to the modern age of online learning, Medpage created a series of minicourses that would qualify for Type 1 credit, which I use to fill in the hours that my lecture attendance does not.

As of this morning I'm done.  5.25 hours on Medpage + 1.25 hours on Medscape where you can lose the credit since the questions seem harder and the articles more involved + six post-retirement Grand Rounds.  Let's see if I remember the subjects:


  1. Partnering with the VA for patient care.
  2. Documentation in patient encounters.
  3. Establishing a Medical Home
  4. Making hospital care more patient friendly
  5. Effects and policy challenges of Vaping
  6. Sickle Cell Diseases and Population Health Analysis
That's more than twelve.

Then we have a required course in Child Abuse Reporting Laws in both Pennsylvania and Delaware.  Since the laws differ, you have to take the three hours of online training separately in each state.  Then this cycle Pennsylvania added a 2 hour requirement for familiarity with the state's opioid prescribing laws.

All done.  Just need to figure out how to fill out the online form, provide payment, and I'm good to go for the last time unless I interrupt retirement by taking a job in Pennsylvania.

Wednesday, December 5, 2018

Money Saving Coupons


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One supermarket, Shop-Rite, made a key wise decision a number of years ago to set aside specialty kosher areas for bakery, meat and deli which essentially gave them exclusivity for us kosher consumers, with a little competition from Trader Joe's whose more limited inventory makes it attractive to empty nesters like myself who do not always benefit from a mega market.  Every Thursday the weekly circular arrives in the mail.  Coupons are noted.  Now that I am retired I can go any time, avoiding the Sunday crowds and likely to find significant clearances on an item or two of kosher meat, for which I should probably set a moratorium as my freezer needs some clever re-positioning to get the door closed tightly.

This week they had a particularly attractive array of coupons for things my doctor thinks I should avoid.  Bulk salmon just right for gravlax, though the price of a bunch of dill was exorbitant.  Can always use cream cheese for 99 cents.  Needed hanukkah candles as our big menorah that used shabbos candles snapped at its base.  Pepperidge Farm cookies, chocolate chips.  They require another $10 purchase, no problem with the kosher but dairy Manischewitz Hanukkah gingerbread house which was not so easy to find.  And we always need another package of paper towels and toilet paper.   Bargain on Morningstar Farms trayfe facsimiles and Manischewitz dry soup mix.  Now that I am home to make supper most days and like to make breakfast, brownies and latkes, eggs at a reduced price cannot be overlooked.  Before you know it, my cart was full, though the paper products took most of it, and my Visa chip debited about $130 from my account, and that's without buying any meat at all.  https://www.foodnetwork.com/recipes/potato-latkes-recipe2-1963445

With the pantry, refrigerator, freezer and other flat kitchen surfaces now saturated, a game plan to eat all this stuff poses the next challenge.  Gravlax takes about 4 days to make and about 10 to eat.  The cream cheese will come in handy.  I've been baking a bit, which is why I needed some more eggs, and could bake some more.  Could make challah for shabbos, that uses up some eggs.  Don't know yet what to do with Morningstar Farms phony Pulled Pork, in part because I never made pulled pork and I don't know if the ersatz meat can be 1:1 substituted for the real thing.  And there is a Festival deadline for assembling that Hanukkah gingerbread house.

Tuesday, December 4, 2018

A Work Day

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Big task list.  There has always been a little tension on major projects like decluttering my study.  Is it better to do a half hour at a time over an extended time or allocate an entire day to just do that.  My inclination has always been to eat the elephant one bite at a time but there are reasons to question that.  My monthly writing assignment, for which I am paid, takes a few hours to research and write. I pick the topic in advance when I find something that looks interesting but the writing is done in one or two large blocks when it has my undivided attention.  On the flip side I keep up with dishwashing pretty much every day.  Grand fleishig dinners, like I had for Thanksgiving and my wife's birthday, generate a few racks worth of dishes.  I do one rack at a time, but multiple racks in one day and generally do not stop for a partial rack.  And there are the hybrids.  In school I kept up with my classwork each day but had marathon reviews the night or two before each exam.



So after maybe a week of mostly recreation from my trip to NYC, a day at the library, a day ill, and a weekend recovering, then birthday and Hanukkah and a return to SERMO, it's time to redirect to the work tasks.  Cleaning the house, writing an article I've been neglecting, making my two desks usable, dealing with a large dental bill that may be erroneous, major shopping with money saving coupons.  All do better with concentrated effort and defined completion points.  Unsure if I am up to the task.

Monday, December 3, 2018

Combining Festivals

Hanukkah has arrived, roughly its usual time on the American calendar, always its usual time on the Hebrew Calendar.  Opened our first of eight gifts, mine being an eyeglass holder to keep behind my bed to keep my glasses from falling behind the bed.  My wife, a cat aficionado, got a cat doll that can be warmed in the microwave and hugged.  We lit candles, greeted each other mostly electronically, took the Delaware Democrats to task in cyberspace for posting a shabbos menorah with seven branches instead of the traditional Hanukkiah with nine.  They updated their image. 

Hanukkah, while festive in its own right with its own special traditions and foods, does not always occur in isolation.  The movability of the Hebrew and American dates and Hebrew leap years comprising a full month every seven of nineteen years, sometimes the Hanukkah season changes.  It can rarely coincide with Thanksgiving, more frequently coincide one of the eight days with Christmas and nearly always merged into the Christmas season.  This year I got a special overlap, with my wife's birthday falling on the First Day, as mine sometimes does during Pesach.

Thanksgiving and birthdays derive from our public calendar, one a fixed date the other with a small amount of variability so this birthday and Thanksgiving are always not far from each other.  I have become the Grand Chef for both and seem to derive my own measure of pleasure from the menu planning to the execution to the cleanup.  Postponed the potato latkes until later in the Hanukkah festival, substituting as the starch shlishkas, a gnocchi-like pasta shaped as a nugget, one of the treats offered to me by my Hungarian maternal grandmother and now propagated, though via a yiddish cookbook recipe.  And we had roast duck, a very rare treat of limited availability.  Royal nuisance to make, again dependent on a classic preparation method from an encyclopedic cookbook, but worthy of a special occasion.  And an almond torte known as torta del re, this one from an Italian Kosher cookbook, another special occasion item, though with readily available ingredients and with modern cooking appliances not very difficult to make. 

So two occasions overlap, a birthday and Hanukkah, neither in competition with the other, unlike the secular festivals which sometimes do undermine each other.  All are special, even Christmas which was celebrated by my taking medical call each year as part of a specialty group and now going out for Chinese like the rest of the Jewish community that day.  We can now proceed with the rest of our Hanukkah for its own sake.

Image may contain: people sitting, table and indoor

Sunday, December 2, 2018

Transient Bacteremia

Since retiring a few months ago my physical health has held up admirably well other than some nagging recurrent lumbar pain.  That got interrupted abruptly a couple of days ago when out of the blue, while researching something at our public library, shaking chills emerged.  I had no symptoms to localize an infectious source.  There was accompanying generalized achiness and a severe tremor that kept me from using my keyboard or cell phone when I got home.  The purpose of this physiologic response is usually to warm the core temperature, which happened about an hour later, peaking at 101.1F, pretty much as my textbook of the 1974 Harrison's Internal Medicine with the bright blue cover described it.  Once suitably febrile, the shaking stopped.  In an hour or two the fever had resolved though I felt exhausted and just a shade achy suggesting this might be a viremia rather than a bacteremia.  The temperature elevation never returned and having cancelled my appointments for the following day, I just stayed mostly horizontal, allowing my return to mostly baseline the day following.  I do not know what caused it.  Being an experienced physician, I recognized what it was, had seen it many times before and never felt sick enough to either call my doctor or head off to urgent care.  Back in action today.

Image result for harrison's principles of internal medicine 1974

Thursday, November 29, 2018

Day after New York



New York, NY.  So nice they named it twice.  And it really was a lot more pleasant than on any of my prior tourist attempts.  Bus ride from home 2.5 hours each way.  The Chinatown Bus driver passed everyone on the Jersey Turnpike but had to stop to replenish the diesel fuel on the way there.  The Macy's area, the drop-off location, may as well been the local mall.  While the flagship Macy's was a lot bigger than ours, the stores along 34th street included a KMart and mainly other chains found anywhere.  At the end of the day, the city bus took me along Fifth Avenue's more tony shops.  Lot's of Christmas shoppers on the sidewalks at dusk, not many shoppers in places that only need to sell a watch or two each day.  Lunch at Kosher deli a few blocks north, a treat to people who do not have kosher deli's and are deterred by the price of Kosher corned beef at Shop-Rite.

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Found my way to the Cloisters, my intended tourist target, via the A Train with a senior discount.  That left a half mile walk to the museum.  Having been to a number of Art Museums the last few months, this one given its reputation seemed a disappointment.  Since I had too much time left, I took the bus from the Cloisters to the bus pickup, a span of 160 blocks which took the MTA Driver 2.5 hours.  I had not been north of the George Washington Bridge in Manhattan.  Pretty nice place with clean buildings that have white brick, some architectural detail and neither litter or graffiti.  School letting out so a bunch of late grade school kids got on the bus, all nicely groomed, none boisterous.  Just south of the bridge appeared the Columbia Presbyterian Medical Center, a multiblock congested monument to health care, much of it aging, some new.  Made it past the less massive Mt. Sinai Hospital, first time I've ever seen it, about 70 blocks south.  As the street got the the 140's, the area appeared more Hispanic, a little shabbier but still without litter or graffiti.  Then I expected Harlem but that seemed largely gentrified with some theological seminaries, a large Barnard presence, more subtle Columbia University campus, and some vestiges of City College.  The shops along Broadway seemed similar to other college towns.  Cathedral Parkway at 110th Street, which I expected to be the southern limit of Harlem, also looked gentrified with a branch of Yeshiva University and some churches and some tasteful apartment buildings.  Then across the northern border of Central Park, turn down Fifth Avenue to the eastern border followed by the bus to the end.  Not a lot of people in the streets until the southern part of the Park.  Museums such as Guggenheim's spiral architecture, a music school, apartment buildings with increasing architectural decoration, signs for doctors who do not have ethnic names and do not say one way or the other if they accept Medicaid unlike the doctors farther north.  Made it eventually to the terminus, too dark by then to see much other than the storefronts with bright lights and the sidewalks, and the iconic lions that invite the scholarly or those terrorized by term paper due dates to partake of the massive New York Public Library.

Found my pickup stop, Boarded an early bus than originally intended and uneventful, restful ride back home.

When I did my semi-annual planning about six months ago, I had allocated three day trips among the twelve initiatives, all to places I had not been before.  Dickinson Plantation, Princeton Art Museum, Cloisters.  One very doable semi-annual project likely worthy of repeat when the next planning session begins next week.

Tuesday, November 27, 2018

Coffee by Percolator

Farberware Classic 8-Cup Stainless Steel Percolator 50124



Way back when, the night before major science exams, I would take out my orange electric percolator, contraband in the dorms, and brew a pot of real coffee after supper to enhance alertness.  It served its purpose.  I do not know where that percolator is now, but I have both an electric one kept in storage and a stovetop one that does not get used all that much kept in a corner of the kitchen.  Over the ensuing forty years, my fondness for coffee, both its taste and its effect, has never dwindled.  Sometimes it came from the school cafeteria, less frequently my percolator.  When visiting parents, they used mostly instant.  I could handle the freeze-dried, the powdered stuff which they tended to get my ooky.  I might still have a jar in a pantry recess, used to flavor mocha or some other similar purpose, but never as a beverage. 

My horizons expanded as a resident.  A place near my apartment specialized in coffee, introducing me to the French Press.  I bought my first coffee cone after a fellow resident introduced me to hers in the residents lounge.  Shortly thereafter, multicup drip machines captured the market followed by the emergence of Starbucks which popularized what the Coffee Connection at Harvard Square had already been doing.  And ultimately the K-cup which allows variety and ease with only a small sacrifice to taste.  That's my morning go, though I still use the cone and the French Press when not deterred by the need to clean the devices.  The French Press definitely makes the best coffee, as it did when first introduced to it.

But my origins remain the percolator, which I took out this morning for the first time in forever.  I had trouble finding the round paper filters which had fallen to the wrong closet shelf, but once in my possession, it's a go.  Opened a new package of New England Donut Shop Blend Coffee, put in four coffee measures, or actually slightly less, filled to the 4 cup mark and let it perk for seven minutes.  Then some Oreo flavored whitener and shake of pumpkin spice in a cup and poured myself liquid to the top.  While other brewing methods have predictable results, the percolator has vagaries of measurement and duration.  This pot came out a little weaker than I might have preferred.  There is a slight bitterness, which I like much as what attracts people to beer.  Maybe the next cup will be with milk or some heavy cream that I have left over.  Too much cookie influence.

But it's good to return to a special treat, one set in personal history, even if there are now better ways to brew that morning coffee.

Monday, November 26, 2018

My New Instant Pot

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It's still in the box on the back seat of my Honda where it has been since purchase about a week ago.  I had $48 dollars to spend, having harvested every five dollar bill that I received in change the previous six months, accumulating $130 of Me Money that way.  Some went for a No Soap Radio, some for an electric shiatsu back massager and the remainder for the Instant Pot which was on sale at Shop-Rite for $50.  So now my culinary skills have moved to the modern age.

First item, milchig or fleishig?  I tried to get some feedback from users on kosher.com but their interactive site faltered so I signed onto Facebook which had a community of kosher instant pot users.  As expected, fleishig uses dominated, particularly chicken preparation.  There was advice to start with pareve, advice to get a second one at the bargain price.  People even get an extra for Pesach, which seems like an extravagance to me but they write that it simplifies preparation for that holiday.  My own meat consumption has not been much and preparation largely limited to shabbos and special events these days, so I'll start milchig.  Got some mahi mahi which should be a suitable introduction.

While I look forward to using it, the real horizon for me might be the common connection to other kosher users.  As I open their profiles, they are mostly young women with young children, scattered around North America mostly but not exclusively, a few men.  Not many bubbes who probably still use the oven or have adapted to the microwave.  We'll see how the fish goes and I'll let my new electronic friends know.