ACP, Medicine's Conservative Jews

I'm down to my last medical organizational membership, the Endocrine Society, having let the clock run out on my membership in the American College of Physicians.  Of all the organisations that would regard me as a defector, I think the reasons for departure most parallel what has become widespread voting with one's feet on the organizational arms of Conservative Jewry, outlined in the Pew Research Report on Judaism in America.  In his book Getting Our Groove Back, Scott Shay devotes a chapter to Conservative Judaism's decline in formal affiliation, if not in practice or a reassembling of talent elsewhere.  Talent matters.  My own experience with the Conservative Jewish organizations suggested that at least the places I frequented were rather insensitive to the talent that people possessed when it failed to synch with Rabbi or macher agendas.  They failed to capture what the participants wanted to derive from their membership, resulting in attrition.  A revolving door of suburban families purchasing Bnai Mitzah for their children had become part of the culture, people never really connected.  Then there were the people like myself who either were connected or could have been but some clash of values never quite got smoothed out.

And so we have the ACP divergent path of what the seniormost leadership promotes and what dedicated internal medicine certified physicians might want of their professional organizations.  I want to be a really capable doctor, the best I can be, and receive a due measure of kavod for the work I put into it.  When I or any ACP Fellow requests expert advise, I want it from the specialist, not his or her understudy in the form of noctor.  The ACP should carry Flexner's banner a century after his report enabled the ACP to flourish.  They have not.  I work hard to maintain my skills.  They should never be jeopardized by the blight that Board Certification has become.  When I read a study, it should be somebody's research.  Meta-analysis has its place but not a dominant place.  And as people like me toil in front of the computer screen, watching our tasks trivialized to clicking boxes reminding people who have weighed 300+ pounds for decades to exercise while our contact time to do really useful stuff with these most difficult medical challenges gets tacitly eroded with ACP complicity when our own organization should provide advocacy does not bode well for their future credibility.

Scott Shay regarded the implosion of the Conservative Jewish organizations as one of the disasters for American Judaism.  And failure to advocate for the real interests of the core medical workforce, what should be ACP's unfulfilled mission, can be no less a disaster for American medical care.

No Response

Sent an inquiry last week to the three ritual officials of AKSE.  We had a week in which the Rabbi was away on shabbos morning.  The Torah reading proceeded in its entirety without those annoying Aliyah Sound Bites that interrupt the natural flow of the chanting and choreography of honors that I've come to expect.  So I asked them if there were any standards of interrupting a Torah reading.  None of them even had the courtesy to acknowledge the question.  I posed it to a reputable Webbe Rebbe who provided me the answer in a day.  There are two conflicting positions of recognized Poskim.  One says the Torah reading should not be interrupted, the other says it may be interrupted to honor somebody or to teach Torah.  So that interaliyah running commentary meets threshold, leaving me with the option of limiting my exposure to it, something I've already done.  Since sending my  inquiry, two of those three gentlemen asked something of me, one to conduct Shacharit, the other to chant a haftarah on relatively short notice.

And last week the head of medical technology stopped by my office late in the afternoon on no notice to promote his agenda on behalf of the hospital.  One inquiry to him in the past unresponded.  Detracts from his agenda.

And finally, there is a controversy over medical specialty recertification for which the Endocrine Society invited comment.  I'm sure a lot of people put in their two cents, as did I.  There was no acknowledgement, though to be fair the new Society President sent a note later that he and other medical society officials had met with them to express their constituents' displeasure.

In our era there seems no shortage of forums for expression, and the things we comment about get seen.  But without the response, which has become decreasingly obligatory as these venues expand, engagement suffers.  AKSE's logo:  Embracing/Engaging/Enriching.  This time I had to seek that interaction and knowledge externally.

Jewish Blogosphere

These last few months I've been trying to give myself a tour of similar souls who toil in the cottage industry of expressing Jewish thought publicly and without any external restraint, irrespective of whether the comments might or might not be welcome.  I found some satire.  I found a lot of organizational cheerleaders.  Some in pursuit of getting even with thems who done em wrong.  A few mavens:  the artists, the cooks, some Rabbis who post their weekly sermons.  Many fewer explorers than I would have expected in an amorphous place devoid of geography yet accessible to most of the world.  If I want to move the furniture in my synagogue, I thought it would be easier to locate somebody else who has moved the furniture in their synagogue.  If I want to do projects like start a journal club or catalog members to target specific participatory invitations, I thought it would be easier to tap into expertise than it has been.  Judaism depends on these little subcommunities traceable to the USY Cliques of the 1960's where life's future Jewish and personal  attainments turned out to have little correlation with being part of the beautiful people.

The Jewish Web has a lot of entries but surprisingly little ability to target what might prove helpful.  It seems much like wanting a list of millionaires in Manhattan and being handed the telephone directory which indeed has the contact information of more millionaires that a person could reasonably contact.  But the telephone directory does not enable you to identify which of the people you wish to contact due to excessive clutter of irrelevant listings.

Somewhere out there a critical mass of Me and Pew defectors floats around, able to articulate how they got onto Judaism's exit ramp.  There are probably places to find dumb rabbi jokes interspersed with dumb rabbi jokes.  It remains by belief, accurate or not, that those who departed the tribal entities to go off on their own really did not disappear but became part of an expanding Jewish entropy which still has much to contribute.  And the organizations have gotten so inbred, that they lack the leaders who can connect external to themselves.   I'll keep looking and keep adding some clutter to the Jewish cyberspace.

Learning Isaiah

With each half-year, I set for myself a variety of projects to pursue for the upcoming six months knowing in advance that few will be completed in the absence of a deadline controlled by external forces.  They include upgrades to my home, my health and my mind, numbering from 6-12 each semi-annual block.  Been a little too casual with my own Jewish study of late, not accessing www.yutorah.org nearly as much as I once did.  So I set aside some reading for myself, two literature classics, Book of Isaiah and one of the Minor Prophets to be determined later.  www.yutorah.org has podcasts of their classes which include lectures on these for their Rabbinical students so a good approach might be to read a chapter or two at a time, then listen to the corresponding lecture from one of the courses.  It will take most of the six months to get through all 66 chapters.  About half the Haftarot come from Isaiah so it's probably the book to study if I want to make myself a little more active in Jewish study than I have been.  Carving out the time should not be difficult as I piddle enough time on Facebook each evening to get through a text chapter instead, though the podcasts will probably take more time.

I think there is a pent up demand for serious Jewish study, looking at the seemingly endless offerings in cyberspace and the dedicated subscribers to major projects like Daf Yomi or a multiyear survey of Mishneh Torah being led by one of the outstanding Rabbis at a regional congregation.  But everyone actively engaged in stuff like this, there is also a popularity to the spoon feeding of stuff like Aliyah Sound Bites that come one's way passively and no doubt last as long as they took to impart.  Fortunately, I think the pendulum seems to be swinging back toward substance.  I need to be a little more engaged in that favorable trend.

MOC

Not written about life of the physician in a while.  As I reach the closing chapters, it seems not so much a downward spiral as a series of impositions.  Maybe what attracted people of my era to medical school, when our generally ample college grades would have enabled other pursuits, was the expectation of independence which has clearly eroded piece by piece.  In rough sequence, first came the lawyers, then the DRG's, then managed care and now we are increasingly gutted not so much externally but by our own people, be they management setting performance quotas while pulling out the means to fulfill them or more recently by our own eunuchoid specialty organizations capitalizing on changes in the Board Certification process as it becomes increasingly onerous, when they should be serving as their constituencies' advocates.

When I took my first American Board of Internal Medicine exam, Jimmy Carter was still President, though about to be voted out.  His tenure was transient but the Board Certification was permanent.  Not that I would ignore my need to keep current on medical knowledge but at least not have a 12% failure rate hanging over me.  As I moved to Fellowship, the rules changed making the certification only good for ten years, then having to be renewed, which I did in 2001 and 2011.  Expect to be retired by 2021.  However,  the ABIM unilaterally changed the rules again, putting time restrictions on the intermediate steps, which I would typically lie dormant for five years while I did other things, to two year cycles.  I could probably find 20 hours every couple of years since I can use that credit for license renewal. What seems to have changed, though, is the pass rate on the exam from 87% to 60% in some of the exams along with the fees to enter the program at all and take the exam a second time.  Moreover, this has moved from a self-assessment, or even a promotional credential to attract patients, to an economic necessity where insurers who pay you require the certification to stay current, as well as hospitals such as mine that require certification to see patients there.  Jeopardizing that threatens livelihood and probably threatens patient care, as those 40% see a lot of patients and mostly do their medical assessments with great levels of skill.

Needless to say, many of our professional organizations find themselves caught in the middle.  Most have sent inquiries or petitions to the ABIM to protest or show concern.  None thus far have tried to pull the plug by setting up a committee to assemble a competing certification process or passing a resolution requiring their officers and committee members to avoid complicity with this by not agreeing to develop questions of modules for the ABIM.  Moreover, out professional societies are at the forefront of providing ongoing medical education to their members, as they should.  More requirements means more courses to give and more organizational income from it.  So we receive a mixed message, our organizations which our dues support have an incentive not to take action against what the membership finds onerous.

My best guess is that by about two years, reality will set in.  The American College of Physicians whose executives have moved on to become Presidents of the ABIM can expect a membership decline as they fail in the role of member advocate.  My membership lapsed without renewal last summer.  But for the most part, you can't fight City Hall, or at least the risk of protest is too high, so most physicians will comply.  And for me a module or two this summer, as I need the Continuing Ed credits anyway.

Congregational Gala

It came and went.  Two people worthy of honor got honored, yet those honors were really a pretext for the true mission of this event, to raise money, which it did.  This event seemed a little reminiscent of a scaled down Bar Mitzvah.  Simple reception hour.  I did not know that the Sam Adams Brewery had come under the supervision of Star-K.  Kosher wine.  A crudité table, which probably would have been better without the pita, since that  requires washing,  Motzi and Birchat, though there was a washing station off in the corner that nobody used.  People shaking hands, greeting old friends not seen in a Senator Coons Age, or not seen anywhere near a shul since last Yom Kippur.    Friendly people, nice people, not that many overt Federation types.  A band that played mostly music familiar to the people of the two honorees’ generation.  Not very many premenopausal women as guests, about the same number of premenopausal women who served as waitresses for the catering company.

Conversation mostly trivial small talk, which is an art in itself that I never personally mastered.  The Senator appeared older than when I last saw him but every bit as witty as when I last heard him.  Food was good.  Been a while since I had prime rib.  Don’t even know where to buy it.  The ad book, the source of the serious revenue for the evening sat a few at each table.  Big ads mostly from other Jewish organizations or elected officials who have a vested interest in keeping in AKSE’s loop.  Don’t think I’ll look at the agencies with which I have had personal adverse experience any differently because of their rather self-interested generosity on this.  Small ads from a variety of dentists, accountants, landscapers and other who feel obligated to stay in their customers’ good graces.  Ironically only one ad from a hair dresser, a mid-size one, despite the reality of the post-menopausal women in attendance keeping their hair stylists in fat city by sporting a ‘do in a color at odds with what nature intended.

And while there really is no Hebrew word for fun, I think those in attendance had an enjoyable break from their usual activities and sincerely wanted to support the two honorees, if not the synagogue that enabled the honors.

But the evening ended leaving a pot of gold as its legacy, perhaps something that might endure longer than the evening, though probably not that much longer.  The two men being honored, one a Rabbi, the other a businessman devoted their adult years to promoting a Jewish future.  How well it actually happened in this generation of organizational decline could be seen in the attendance.  And the purpose of raising the money, to secure a future for our congregation, seems to be running in parallel with this.  It may be honorable to raise money but if it cannot be applied in a manner that looks ahead to meaningful projects that attract devotees, they you are left with a room of older geezers like myself congratulating each other on how wonderful we all are while missing the real opportunity to apply the success of our efforts in a sustaining way.

Leadership Generated Attrition

Been thinking of writing an essay about how depletion of Jewish organizations and medical societies over my adulthood can trace its origins to the people who run these organizations.  I think it is true.  We saw it to some extent in the last Presidential election where the highly publicized donors in the Jewish realm could not capture the Jewish vote for their candidate.  That synagogues, JCC's and regional medical societies now struggle seems obvious.  The revered leaders have passed on, never quite grooming individuals of comparable character to take over.  Or perhaps they did groom them but at the expense of adaptability to the constituency.  Personally, I am down to my last medical organization, The Endocrine Society.  The JCC membership gave way, I have been repulsed by the experience with our local Federation and the Federation Types, my synagogue gets my dues but not the talent or creativity of thought that has far less value to the leadership than does the money.  I used to be a participant in all of these things and with the exception of Federation and maybe a previous synagogue, I did not really find any of the organizations outright objectionable, yet I am very much a part of their membership depletion.  To a large extent I am part of their talent depletion.  Ironically, the only medical organization left is the one where I would be regarded as too paltry a maven to be a serious intellectual contributor.

I find it difficult to detect a common thread that would not only capture me personally but a much larger population of former participants.  Rav Eliyahu Dessler divided people into Givers and Takers.  Maybe we are all Takers who found nothing worth taking.  Maybe we are fundamentally rebuffed Giver wannabes.  Each organization, Jewish or professional, exacts a serious financial commitment for which there is little return.  Certainly synagogue fees have escalated to where it really is not a good consumer purchase.  Medical organization fees usually run a few hundred dollars which is not really exorbitant relative to other professional expenses.  JCC is really  more of a consumer purchase of facilities and services while Federation expenses are to some extent voluntary.  No, I think the attrition has more to do with the value of connectedness than it does of expense, with the exception of the synagogue where some of the fees can be daunting and to some extent interpreted as a form of extortion to purchase a Bar Mitzvah.

Since it is easier to write about me personally than to generalize in the absence of assessed data, I'll go that direction, with a reasonable assumption that what I experience and act upon, others experience and act upon.  I used to attend Shabbat morning services every week unless I was on medical call or out of town.  Now I force myself to go about half the time to my own congregation, make a few entrances a year at other congregations, some more to my liking, some not, and for the last few years have dedicated one Saturday morning a month to my recreation, usually in the form of a day trip.  Guilt level = zero.  Number of people who have tapped into my mind to assess this transition also = zero.  And if they did, I'm not sure I could tell them.  But as an observer I feel little connection to the Rabbi or the relative triviality of the comments, I have found the operations of the governance sometimes offensive and have other outlets to enhance my engagement with Judaism.  Spending two hours enduring a series of Aliyah Sound Bytes does not measure up to what I could be doing instead, whether that be a schlep to Beth Tfiloh in Baltimore where I return with a shabbos that I could not otherwise duplicate or a day taking in the pleasantries of Hershey Park.  Shabbos, or really a form of half-shabbos, has not disappeared.  I do not write, service the car or use electronics as my form of reverence to the concept of avoiding melacha but I am not feeling any obligation to revisit some relatively negative encounters and impressions of synagogue leadership during limited time that I largely dedicate to myself.

For many years, as High Holy Day Torah reader, my very consistent observation was that the VIP olim had a generous generous handshake for embrace for each other but a perfunctory handshake for me from about half.  The work that went into this for their honor was their due.  Or they never quite captured Ben Zoma's concluding aphorism:  Who is Honored? One who honors all living things Avot 4:1.  And lets not omit USY which had its ongoing cliques that endure at a price.  But they also have a leadership that excludes holding office kids who opt for being on the high school athletic teams on shabbos.  They value obedience over talent.  Before long they find themselves with neither.

So yes, the organizations have depleted numerically.  But the people who depart for elsewhere or sometimes nowhere, as the much commented upon Pew Research report attests, take away talent and energy that could have been tapped but wasn't valuable enough or convenient enough to either seek out or accommodate once identified.  Cloning more of the last generation's leadership mindset only invites more attrition.  Reb Pogo's observation has been vindicated many times:  "We have met the enemy and he is us."