Deadlines

For the most part, I do not like to work with firm deadlines but the externally imposed ones clearly make me more productive than the ones I impose on myself with utmost flexibility.  I did manage to get my office closed despite my secretaries' preference to drag it on indefinitely. 

These next few weeks, I have two major talks, one at AKSE Academy next weekend and another in mid-February for Mercy Hospital's Grand Rounds.  I have been working on them but the looming presentation date has started to impose a greater measure of focus.  AKSE sources are nearing completion with the upcoming week for editing.  These next two weeks I need to devote attention to making my slides for Grand Rounds.

Adopt a Family

Mercy's Endocrine section manager sent me an email that the group was providing Christmas presents for a local family, assigning me a 13 year old boy, who I know nothing about.  This being my first time, I asked the manager what the minghag b-makom, or local custom, happened to be.  I was mostly concerned about amount, eventually learning that my partner sent a check for $50.  While I like to give money as wedding gifts or even Bar Mitzvah presents where the funds can accumulate and the recipient starts out with savings or tuition, for events that will occur again, like birthdays or holidays, I prefer to take the opportunity to think about the recipient and how I might add a some form of more short term pleasure.

I know this fellow's age and that his family is needy.  No other information.  I do not even know if he is Christian and celebrates Christmas, as the West Philly area has a fair number of Muslims, either from an enclave of Bangladesh or African families, or African Americans who discovered Islam in the state or federal correctional facilities and who found the requirement for abstaining from drugs and alcohol useful for their future or maybe who found the doctrine of selective rationalization of violence attractive.  I know nothing about the recipient.

While it was my natural inclination to spend all $50 on a single gift, figuring that he'll never accumulate that sum to spend on himself, my wife, who has done this before, recommended that I divide the total into three gifts.  The office manager concurred with my wife, so I did. 

Several years ago the Jewish Theological Seminary's TOR-CH posting site contained a thread in which two orthodox missionary types electronically heckled the Conservative institutional structure and the mediocrity or less that has accrued from it.  The more capable of the two commented to me privately that he really wanted the Conservative participants to upgrade their Judaism properly which in his mind meant being more like him.  I politely responded that the goal should not be to have them more like him but better reflections of their own aspirations.  Gifts can get into a parallel trap.  I would like this early teen who I know nothing about to be inquisitive, creative, studious, responsible, all the things that I admire and then project upon him, though maybe not what he admires or even fulfills the intent of pleasure.

In the end, I divided the allotment relatively equally, settling for a Phillies sweatshirt where one can never go wrong, a telescope, and a soft-tipped dart board.  It does not fulfill any of the criteria I set ages ago for gifts for my secretary's son, who I do know, which must either make noise, get him suspended from school, or bring him to the ER.  None of these for the anonymous recipient.  Unless maybe if his evolving hormones and id prompt him to use the telescope to forgo looking  at the heavenly bodies in favor of a more earthly body belonging to cute chick in the apartment across the street.

Weekend on Call

My first weekend on call at Mercy.  It was definitely a quieter place than Christiana, with four new consults and about eight others who needed some kind of personal attention.  There were not a lot of consultants or even ICU people or surgeons milling around by early afternoon, with the assigned hospitalists and a few residents assuming most of the patient care.  On Saturday afternoon, the hospital hosted a community health fair so I agreed to occupy the ASK A DOCTOR table for about 90 minutes.  A few folks came by including a couple of diabetics who needed some professional attention, but mostly folks with minor events that would not ordinarily incur a medical visit but as long as somebody is there to look at the rash or sore shoulder for free, why not.  A physician who charges nothing is worth nothing (Bava Kama 85a), though that comment comes in the context of just compensation for an injury which includes payment for medical care, which by Talmudic requirement has to be mainstream care.  I must say, I enjoyed being at the table, watching the people go by as I sipped on a Diet Coke.

Then Sunday I did real on call type of work, a slower pace that enabled me to think about what I was doing, instead of the Christiana burden of just getting through the enormous census and unending cell phone interruptions.  Definitely a more civilized experience, and I suspect a lot better for the patients to have a doctor who is thinking more about them than about the tasks that lie ahead.

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.