Blank Canvas

Our new secular year has commenced.  Predictions and good intentions at the outset have a way of being faulty before long.  With good fortune having come my way, there seems to be relatively little that I need that I currently lack.  More energy and motivation, perhaps, but no material items.  A better future legacy than I've amassed thus far, perhaps.  Professionally I've gotten into the groove, given up my futile inclination to make Electronic Medial Record keeping compatible with optimal medical care, contenting myself to toss a few harpoons at the management that salutes this mandate and the non-participants in medical care who harbor a delusion that it will accomplish something other than what will really accomplish.  But there are things of personal gratification that can be accomplished.  After some pondering of what I value and what the realistic opportunities seem to be, I afforded myself twelve things to pursue.

1. Beer

While I lived in walking distance to America's largest brewery and took advantage of the proximity by walking there periodically for the Anheuser-Busch tour and tasting room, this was beer ordinaire.  As resident in Boston with a fondness for an occasional treat at Legal Seafood, a mug of suds would usually accompany supper, with the bar offerings for this expanding my culinary horizons.  Eventually a craft industry developed while importers made available choices that had been available elsewhere for centuries.  And it's not a particularly expensive adventure as creature pleasures go.  There is no reason why I cannot sample one that I've not had before twice monthly, once in a bottle at my own table and once at one of the growing number of places nearby that have extensive offerings that I could not possible sample in their entirety.

2. Professional

I work in an inner city taking care of primarily diabetes.  My folks do pretty well but there are a lot of statistics to suggest that their outcome under the best of circumstances lags behind where it might have been if their ethnicity and economic standing were different. I am in the perfect place to study this and my own professional Endocrine Society has an initiative to make resources available.  Unfortunately, the Endo Society is dominated by academics who are more interested in why they cannot get minority research subjects into clinical trials than they are in why they fail to derive maximum advantage from what exists for their care now.  It's worth a try to get some funds and absorb a resident into this type of project for which our patient population may be a prototype for a very large medical opportunity.

3.  Family

I do not neglect my family but they seem to work around the odd moments more than having pre-arranged time to do things together.  The priorities on my to-do list seem to need some revision.

4. My Blog

This past half-year, it was my intent to make my blog a forum for Jewish laytzanos with some medical cynicism thrown in.  In the process, I explored the world of Jewish blogging.  To my pleasant surprise, mine seems to have a niche with a largely untapped audience of potential participants.  The genres come in a number of forms.  The most consistently funny and appropriately cynical comes from www.frumsatire.com.  Heshy writes a lot more frequently than I do and his wit attracts comments.  His draw, though, is a limited Orthodox perspective that lobs its share of darts at misconduct and hypocrisy.  The other genres come from a mixture of Rabbis who want to teach something or Conservative cheerleaders of various types who cannot understand why they are experiencing an affiliation crisis.  What seems to be missing is my perspective of people who are loyal to ideology but look at the leadership as a mixture of operators and buffoons not up to the task of matching the Jewish excellence that people seek with the actual experience of participation.  The Pew Research study suggests that the people affected by this type of disillusion and desire for something more engaging might be huge and currently unfulfilled.  I have to figure out some better way to attract readers and engage in electronic sharing of ideas.

5.  Loyal Democrat

Among Will Rogers' many political quips, "I am not a member of any organized party — I am a Democrat."  For most of my voting life, I've looked at the political branch points much as I've functioned as a physician.  There is a problem to solve or decision to make, look at the options and pick the one that seems most likely to succeed within the bounds of Derech Eretz.  Umpire, Judge, Doctor, Scientist.  It is what it is.  Sure there are elements of competence and elements of morality that influence choices but until the past ten years, public positions that fall into the category of evil in America have been increasingly marginalized.  But wicked as a concept seems to be having enough of a resurgence to justify some effort at resisting it or at least pointing out what it is.  From the days of Amos and Isaiah, it has been unseemly to accept people of title who victimize vulnerable people in the name of expediency or social order.  That any support exists at all for denial of science to get votes or policies that deny people their due participation by placing stumbling blocks moves me to become more of a partisan in the other direction.  While my region has become solidly Democratic by affiliation, with even the elected Republicans for the most part staying a step ahead of venal, that is not true other places.  I have to offer my help in some way this half-year.

6. Writing

Among the things that intrigued me this past year was the Pew Research study on Jewish trends in America.  I might be the poster child for this and my declining shul might be the organizational prototype.  I am loyal to ideology, less respectful of the organization that brings these principles to public expression.  Since the release of the report, I've read a lot of hand-wringing from the depleted organizations but not a lot of accounts from the very people like myself who voted with their feet.  It is an experience that needs to be expressed in the right forum

I have also become something of a neo-Hellenist these past few years.  Denominationalism has declined.  There is an inherent beauty on Friday nights at the local Reform congregation.  A recent Orthodox wedding I attended reminded me that this can also be an enduring connection to Jewish life.  Exposure to quality knows very little ideological distinction as the Jewish Hellenists, the Jewish Iberians and those who rejected classical Orthodoxy in the 18th century in favor of Hasidism which advanced the value of each individual taught us from time to time.  Another idea not publicly expressed often enough.

And I've not contributed to the medical literature in a long time.  Need to remind everyone that life as a doctor has its glories and its frustrations.

7. Weight

A recent visit to Happy Harry's gave me access to a digital scale for only $9.99 so I bought one.  My weight recorded at 167 lb.  In the last two years I've had to move to the next size shirt and replace some pants.  My tailored clothing hardly gets worn but it still seems to get me by.  I'm more tired than I think I ought to be.  My feeding habits differ considerably from the advice I give to the chubby folks who visit my exam room.  I need to get serious with my health.  This takes a lot of forms, but for the most part, things that get measured get accomplished.  While I could keep score on medicine use, lab results, or clothing size, weight seems to be the most consistent measure.  It is also a byproduct of the efforts that promote other facets of health.  So for Day 1, I ate breakfast, went for a walk, shopped for a waffle maker that I did not find at a suitable price but at least it will help me shift some calories to earlier in the day.  Target weight by July 4th: 155 lb.

8. Shul

AKSE and its leadership have not endeared themselves to me this past year.  To keep my interest in Jewish things afloat and at a superior level, I accepted the logo of Engaging/Embracing/Enriching for the presidential delusion that it is and either took a sabbatical for six months or went on strike, depending on perspective.  But I read, commented on people's blogs, wrote to authors of things I read, resumed a weekly Parsha review.  Basically, replaced the things the shul should have been doing with other forums that advance me better.

We had a mandatory congregational special meeting a few weeks ago to vote on the Rabbi's contract extension and deal with the reality of nobody wanting to be left holding the Congregation's bag as President when the music stops not too far into the future.  While it had been my impression that I was the last critic still there, with the final remaining handful of loyalists who want to preserve the memory of better days until the lights go out for the  final time.  From the comments from the floor, largely by members of long standing, the dissatisfaction with a marginal experience that is not realistically marketable to the larger community seems broader than expected.  After the meeting I responded electronically to the three people who made the most substantial comments, responses of very little optimism.  While reversing damage may take some doing, it is possible but needs some fundamental revision of how people think, undoing the Peter Principle that dominates the Executive Committee, and having the congregants insist that the place function like a university instead of a Hebrew school even if it means making the Rabbi a figurehead or mascot.  I will try to identify and fulfill two needed projects that really are engaging.

9. Dad

My father died intestate in 2009.  He had a small amount of assets, too little to make a material impact on me or my brother, though probably would be welcome by my sinister.  I was the only child who remained connected to him for his final two decades, so I never felt much urge to pursue this.  I really should close the chapter, distributing the funds as the laws of Florida require.  I will get an attorney to take this over or it will never get done.

10. My Refuge

The mortgage has been paid off for decades.  If I wanted to get a Christmas Tree, which I obviously don't, I would have no realistic place to put it as there do not seem to be vacant corners anywhere.  I do have a few spaces that I could call my own.  There are two desks, a large one in what was supposed to be a study room but has become a repository for whatever.  And a smaller desk in a corner of the living room that really is mine.  And there is my bedroom, or at least my half of it.  At the moment I would call it half a queen size bed where I sleep, read, use my tablets, and groom in the adjacent bathroom.  There are other things that I would like to do there other than store stuff.  Making this half-room really mine occupies an important goal for the coming six months.

11. Guests

While I very much need private space, a lot of the decisions I made for my house in the thirty years I've lived here were predicated on creating a welcoming public space.  Our open houses have been two celebrations of childbirth and shiva for three parents and one gathering for my fellowship comrades, plus some birthday parties.  We have good living room furniture, good dining space, a fully equipped Kosher kitchen with my own culinary skills enhanced gradually over time.  But no guests to share this with us.  Since goals need to be specific to allow measurement, I set a quota of four guests in the ensuing six months.  That means I have to make the public areas more presentable first but I do not anticipate much difficulty with this.  Finding guests and occasions may pose more of a challenge, but four does not seem that many.


12. Day Trips

Several years back I allotted one day per month to visit a place I've not been previously.  My efforts took me to the Jersey shore on and off season, the Yuengling Brewery, Gettysburg and regional wineries, Maryland's eastern shore, the Poconos, and elsewhere.  I acquired a special liking for tours of odd mansions turned museums.  In addition to the interest that the sites create, this also becomes Me Time.  Getting to these places takes some planning, affording me a couple of private hours in transit in my car, with the ability to stop en route pretty much at whim.  I could count on this time set aside for myself.  Since I have no plans to expand my shabbos morning attendance at AKSE beyond the current twice monthly, I should be able to insert one of these day trips each month to boost my spirit as it has done in the past.

Twelve projects this time.  All with specific end points, none requiring significant hired assistance.  All creating a sense of accomplishment that can be a little elusive at times.

Herds

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.

Computer Upgrades

Our hospital patient care system was sold to the management with a hint that they would collect their money faster and in greater quantity.  In the minds of clinicians, the core business of the medical center is patient care with revenue as the byproduct but too little attention was given to the clinical capacity of our Electronic Medical Record which has been a struggle to maintain.  My clinical notes are now pages of cut & paste and carry over from last time.  The designers had the saichel not to put spell check or grammar corrections into the doctor's note writing.  I and many others have learned to leave the grammatical errors in the text as the only way a recipient reader can wade through a multipage report and find which few sentences came from the doctor.

Next week rolls out an updated version.  It would be hard to create a downgraded version of NextGen.  In preparation all users had to take an on-line course and a three hour lecture course to figure out how to use it.  I didn't really figure out how to use it as much as I learned what it could do.  If you were to ask me to add a series of fifteen 3-digit numbers I could do it accurately in a couple of minutes, not so much because I attended a few blackboard sessions in fourth grade but because there was a certain amount of drill and experience that accrued as a user.  My many complaints about prescription writing, scheduling tests, creating lists of often used medicines, replacing inane pharmacy defaults with defaults of what I might actually ask somebody to take, all of these were always there but nobody really showed me how to use them the best way or checked with me in two years to see how it was going.  So while I am in California later this month without the patients coming at me, I will try to set a time aside to customize this in a way that makes it more useful.  The notes will not get more professional as a result but with a little luck I will be able to look at the patients more and the screen less while we occupy the exam rooms.

Electronically Challenged

It took a geek to make my new iPod functional.  It's still not entirely functional.  Electronic Medical Records as I have used them the last three months impede my ability to think about patients.  My three computers, the main one, my laptop, and the one on my desk at work never seem to work at peak function.  And I get ripped off for most of the services I am compelled to purchase for these.

In a prior generation, when I was a potential geek on the sidelines, it was the cars that got enthusiasts enthused but irritated the rest of us by costly breakdowns for which we were dependent on people a little outside the main stream to get us mobile again.

My patients may have similar comments about me as their Patient Repairman.  I did not create the complexity of their physiology nor did I cause its malfunction, at least not initially.  Things are generally repairable and upgradable.  I do not perceive doctors as geeks the way I regard computer experts or auto mechanics, though the public may not concur.

This new calendar year, I will make a better effort to understand my electronic resources and bodily resources and use them in a more functional way.

Happy New Year.

Electronic Medical Record

My first day in Mercy's outpatient Endocrine Office, saved by no-shows which enabled me to struggle with their electronic medical record, a system called Nextgen.  Our financial institutions and travel systems have taken full advantage of computerization, though our medical systems have been laggards.  While I think there is much to be gained, the systems that I have encountered do not seem to be able to template a complex present illness such as diabetes particularly well.  One worthy project might be to compare dictated History of Present Illnesses with those templated.

Electronic Outpatient Records

This week I completed my formal training on how to enter data on Endocrine outpatients at Mercy Catholic Medical Center where they are implementing an electronic record, to begin on my second day on the job.  Over the years I have become something of a medical craftsman, not quite an artist who takes creative liberty, but somebody very proficient who can discern one person's situation from the next.  It came as a shock to encounter a computer program that can be clicked in minutes and generate a relatively nonspecific narrative about diabetes.  It reminded me a lot of my residency time of despair when assigned to the coronary unit.  I quipped in the 1970's about templating everyone's history with substernal chest pain of x hours duration that radiated somewhere, as where usually didn't matter much unless straight through to the back where thoracic aortic dissections go.  You enter the age and the response to nitro if any and you could save yourself a good deal of writing.  These histories didn't matter much since everybody got templated in their care with cardiac enzymes and an ekg.  The differences in the ekg's mattered as did evidence of congestive failure but for the most part a jaded resident like myself could safely conclude that most angina follows a pattern that leads to uniform lab testing and a small variation in decisions with little nuances of history not all that essential to decisions.

That is not the case for diabetes where the difference between me taking care of it and the primary physicians or non-physicians taking care of it are the nuances of history.  There are responses to individual medications, as virtually everybody who comes for consultation arrives already unsuccessfully treated.  There are end organ symptoms that belong in the HPI, not the ROS.  It is extremely hard to template that but people try.