Disengagement

This year marks the Chai anniversary of a seminal, oft cited sociological treatise, Robert Putnam's Bowling Alone.  I've never read it but plan to when I complete the novel that I had earmarked for the second half of 2018.  Basically, he traces the decline of participation in organized social activities over about a generation prior to its publication.  As I retire, I find myself removed from my last pageant, the daily professional adventures of endocrinology.  I pay dues to a few things, the national and Philadelphia Endocrine Societies, Adas Kodesch Shel Emeth synagogue and its men's club.  I no longer pay dues to the American College of Physicians, the Medical Society of Delaware, the American Medical Association, nor have I been a financial participant with the Jewish Federation of Delaware for over 20 years.  I register Democrat, vote Democrat more often than not, but have never been a more than a nominal donor.  I am a proud alumnus of two fine universities.  Any donation to the larger one would not move their fortunes at all and would not be sufficient in amount to get my name engraved on a flush handle anywhere on campus.  My fondness for my medical school knows no bounds and they do get some money with no hesitation, but I do not really belong to any of its organizations.

Since Woody Allen accurately recognized that 80% of life is showing up, I do not show up all that much.  There is the annual Endocrine Society Meeting, too expensive now without the hospital subsidy.  The local Endocrine Society Meeting which occurs monthly will continue, though I have not really made a lot of new friends there.  I go to shul on shabbos but I never get the sense that my intellect and energy have much value to the leadership so activities of years past have atrophied.  As soon as I retired, I volunteered for a Democratic campaign.  One candidate took interest but not much became of it.  I signed up on their web site as a willing participant but I think their executive director would prefer Beautiful People with money or yes men who will not have the candor to tell them when they might be undermining their own potential electoral support.  In summary, I look like a prototypical Bowling Alone  individual model.

Despite not having been a meaningful Federation donor since 1994, though supportive of some of their constituent agencies generous with funding of Jewish projects elsewhere that would likely have gone to them were the experience better, for some reason I found myself back on the mailing list of Federation's monthly, used to be biweekly, publication.  It is kept on a display rack at shul, where I have browsed titles, clenching my teeth perhaps when I come across something that praises one of my travails of decades past, but never read any of the articles.  I recognize some authors, sometimes written by people of laudable presence, sometimes by people I found venal, but mostly not known to me, with expected turnover of participants expected over my twenty odd years of avoidance or maybe more active shunning, while I become a part of a larger trend of Jewish participatory entropy.

Two articles appeared in print recently, one from a globally distributed publication The Forward and the other a locally distributed Jewish Voice, the periodical of the Jewish Federation near my home.  They look at the Holy Days and at Judaism's trends in America very differently.

https://forward.com/opinion/407183/so-called-jews-of-no-religion-are-the-impetus-for-a-jewish-revolution/   "So Called Jews of No Religion are the Impetus for a Jewish Revolution"

Has the significance of the High Holy Days changed for you across the years?http://www.omagdigital.com/publication/?i=521893&p=&pn=#{%22issue_id%22:521893,%22page%22:36}

Has the significance of the Holy Days changed?  For the Rabbis responding to the question in The Jewish Voice, they are the anchors of tradition, at least in their homes, where families gather.  It's a form of keva, familiar people not seen in a while, familiar recipes on the table, familiar tunes that get brought out once yearly.  There are some elements of that for me, though very different from what it once was.  My attachment to the Yomim Noraim probably ended in college.  In high school teens were isolated by my synagogue to sit for a reduced fee in the mezzanine of a local movie theater that was rented for the occasion.  The people with me I knew from school, yet for those days we were separate from school.  While afforded unimportant status, we had the best seats and always air conditioned.  In college, the Holy Days were always a mixture of new people, the freshmen, and old friends not seen since the year before. There was community, even if limited to showing up there while the rest of the students threw frisbees in the quad.  We wore ties, something that would not happen again for a lot of us until next Rosh Hashana.  There were no longer familiar foods,  We separated from our families to be with other students.  I could sit anywhere in the auditorium I wanted, or at least on my side of the mechitza.  We had students conduct the service.  It was ours.  Graduations came and that was all gone, never to be recaptured.  Returning to a suburban synagogue, something just shy of a cathedral, with lots of people there who would never be seen again, not at work, in class, or in synagogue until next year prodded my cynical yetzer, neither tov nor ra but probably accurate.  I stopped focusing on the Holy Days as central, looked at those services as maybe a civilization reversal from the core of Judaism which is how you live on all the other days.  The respect for institution took a hit and it never recovered.

From the perspective of the Forward, in the article written by their editor in chief, I may have been a generation ahead of my time.  Attachment to the institutions and even to the practices did not sustain itself.  We can argue whether I helped bring it down as part of my generation or simply watched others do the things that made participation in the institutions unattractive, but there really are Jews, very valuable ones, who have departed not only the institutions but the beliefs that those institutions were designed to promote.  They have no compelling reason to recapture the recipes their grandparents made or to fly back to their hometowns, something their great-grandparents could not have done even if they wanted to.  While assembly of family for the Holy Days re-establishes this as sacred time for some, in the greater reality of Jewish history and American Jewish history in particular, there is a bit of myth to this.  People changed towns frequently, which is why the various desciples of the Ba-al Shem Tov are all known by their name and by the place they established their community.  In America, the reassembling of families only goes back about three generations though may be a central attribute for that middle generation, which is mine.

Rather, Bowling Alone, the hesitance to affiliate, affects Judaism as much as it affects political participation, attendance at PTA meetings, or enrollment in bowling leagues.  While the Holy Days offer a focus, a set time or keva to declare Jewishness if only for a few days, they do not really reverse what seem to be mega-trends, and alas, probably for cause.

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.

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.

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.

Exit Ramps

Steering onto the exit ramps of public Judaism and of medicine.  Both have a fair amount of traffic.  Both have created an attachment for me over a very long time in some form.  Yet each has become more of a private calling than a public expression.  There is a superb lecture on character as a prerequisite for leadership positions in Judaism.

http://www.yutorah.org/lectures/lecture.cfm/789822/Rabbi_Yona_Reiss/The_Importance_of_Character_in_Torah_Leadership_Positions

Rabbi Reiss cites sources that require effective Rabbis and other communal leaders to have both personal character and the willingness to irritate their constituency for the right cause.  I have found no shortage of people willing to make decisions that generate leadership induced attrition.  And at times people who do this conduct themselves in a way that is beyond reproach, but too often not.  And too often what is promoted as the right but unpopular cause is both faulty and unpopular.  There are limits to what people will accept, giving many a wannbe Jewish leader the Pyrrhic victory of a noble purpose but no talent to implement his vision.

Medicine takes a parallel approach.  No shortage of distinguished accomplished charismatic medical school alumni who engage in dastardly conduct.  Attrition may be a little harder in this forum where people depend on this type of activity for their livelihood but underparticipation seems rampant.  Clinicians have very little incentive to fully engage themselves in the pageant of medicine, opting instead their own niche, whether that be their individual practice or their lab.  Medical societies lose their purpose.  The American College of Physicians moves toward noctor parity as a surrogate for their own physician participation.  People still see patients and run their practices, but they are on the exit ramp just the same.

Board Exams

An every ten year ritual, starting about four years ago with open book self-tests and this horrid thing called a Practice Improvement Module that started out as a legitimate assessment of how well or poorly I communicate with referring physicians but morphed into a series of complex work flow diagrams when my two secretaries and I were the only ones there to do work.  And now the exam.  The patients in my practice modules and on the last two exams don't resemble what I actually see most days.  I do not think I've ever seen a Fragile X Syndrome or a McCune-Albright "coast of Maine" cafe-au-lait spot.  I've been studying from practice exams written by various professors whose biases can be detected from the questions but at least I can extract the principles that I am expected to know from the questions.  Did well with the diabetic questions, stunningly poorly with the adrenal questions and somewhere in-between with the reproductive questions.

This is big business.  I paid about $1000 to enroll in the program, $120 for the review book published by the Endocrine Society, and the outlay for the review course will set Mercy Hospital back most of my contracted Continuing Education allotment.  The pass rate for Endocrinology is reported at 77%, the lowest of any specialty.

To be fair the American Board of Internal Medicine which sponsors this, it has moved ahead of the fraternity hazing of ten years ago.  There is legitimate educational content to the practice sessions, the people I've dealt with by phone have been responsive and professional, the Old Boys have been retired and replaced by a CEO from the American College of Physicians who at least has a sense that an annoying process needs to have some off-setting benefit.  Still the exam looms a month away as I continue to struggle with the review book and head off to the intensive review course in Cleveland in a few days.