Break from Sermo

While work can seem something of a pageant with doctors of various specialties and assorted training levels, nursing staff, secretarial staff, management and maintenance, sometimes an escape to a different collection of peers adds to the satisfaction.  A number of online services have created communities of physicians to which I subscribe to two.  Sermo has become a daily destination, a mosaic of specialty mavens, people passionate about their politics even when at the fringes of morality, downtrodden types tilting at the insurance company or government windmills, and handful of bon vivants in a relentless quest for their finest personal indulgence.  My community in cyberspace.  I have created my own niche there, a hormone maven, a prototypical Jewish voter and devotee of Jewish culture and practice.  I'm very much part of the group, a group that I really do not have any place else.  And while the Pirke Avot aphorisms of Hillel conclude with Al Tifrosh Min Ha-Tzibur or Do Not Separate Yourself from the Community, the attachment sometimes crosses the line between sincere fondness and less healthy addiction.

So it is, I made a decision to take my leave for two weeks, starting yesterday.  The first day was not easy, as I had posted a comment on gun control to which colleagues who derive pleasure from shooting a mallard out of the sky took exception.  There are nine more comments that I have not read and probably will not read, at least until my return.  My Google Chrome home page includes  instant links to Sermo, Comcast, Facebook, furrydoc, and Medscape.  Work disallows entry to Facebook leaving me with checking my personal e-mail as the surrogate for not accessing Sermo during the periodic slack times on not so slack times when I feel I might have something important to contribute.  I've never timed how much time I spend there.  Some of it undoubtedly classifies as legitimate work.  When I host residents or medical students on elective, I invariably use some of the other people's posts on endocrine topics for teaching.  My own contributions answering other people's endocrine queries or bantering different medical thoughts with some very learned colleagues of different perspective adds to my own skill so that would justify paying me for the interactive time as well.  And I've asked guidance on my own cases that seem off the beaten path.  I've never neglected my own professional tasks to make political or cultural statements in cyberspace, though perhaps I could have been doing some billing or record keeping or keeping my desk more tidy during those slack moments which never amount to more than ten or fifteen minutes at a time, unless using the service for real professional activity..

So Day 1, resist temptation to click the icon.  Almost there.  Next step, do something else with that time.  Since they are all nearly all brief moments of time, a form of ADHD heaven perhaps, what else might I do with ten minutes instead.  My really big projects, it turns out, generally require much larger concentrations than I give to Sermo.  But there are charts that can be signed, maybe some hospital bills that can be generated, a more orderly desktop created and maintained.  As satisfying as connecting to my professional colleagues has been, there is an opportunity cost, one that is small but real.  It will be interesting to reflect back in two weeks and see what I actually did instead.

Unworthy

Why have the mainstream Jewish organizations spiraled downward during my adult lifetime?  That's been my exploration while I put my own principal organizational attachment, the synagogue to which I pay an exorbitant fee to belong, on the back burner for the second half of this calendar year.  I've now read pretty much what I plan to read on this and take Ron Wolfson's advice to tell my story.  We each have our story.  For every patient encounter I start by soliciting theirs, either verbally of by review of records or more typically a combination.  If I am successful as a physician, the ability and the obligation to connect with those multitudes of tales has enabled that.

So I'll start with two vignettes, same theme but fifty years apart.  The first took place as a camper at Ramah in Wingdale,NY the first year it was opened.  The grand poobah's of Conservative Judaism put a lot of effort into this, creating a living Jewish environment, deluding themselves into thinking our evolving language capacity will enable reasonable facility with conversational Hebrew, all to attract their most promising students, the people that their crystal balls told them would propel Conservative Judaism into the next generation as a vibrant and enduring branch of American Jewish ideology.  At the conclusion of the summer, the head counselor assembled all the campers to offer his final charge to the departing crew.  Few remarks remain with me for half a century but he indicated that the dozen or so kids who got homesick or did not have a good enough time to tough it out and left early were not real Ramah caliber campers.  They were inferior in some way, not the leaders that the camp sought to develop.  Well, it turns out that I did not have an Ace time there either but toughed it out partly for lack  of a better alternative and not wanting my parents to experience financial loss.  But I made it clear to them and to my Rabbi who was very much attached to the Ramah program, that I would not be going back.  Most of our congregational children had a similar experience and similar response.  While they tried to negotiate with me the option of waiving the camp's rules and allowing my attendance at a site other than the one determined by my home town, I would want no part of chancing that type of summer again.  And of course the assumption was that there is something wrong with me for not appreciating what was offered to me, irrespective of my assessment of the actual experience.

We fast forward to the most recent High Holiday where I encountered the same thought process transposed to a different situation.  Again, amid attrition threatening existence, the treasurer appealed to the congregation for voluntary supplement to dues, including in his remarks that the people who remained were the worthy members.  Anyone who preferred something else or even nothing had to be less worthy in some way.  Not, let's become more adaptive but let's get more money so we can do more of the same for the people who really deserve it.

In between, there have been no shortage of similar messages.  How can you snub a communal leader?   I found the experience with him or her vile, that's how.  How can you not give to Federation's SuperSunday campaign?  Like the other 18% who decline, I had an adverse experience with the leadership or the funded agencies.  There must be something inferior about me if I walk away from irritating Aliyah Sound Bites and find the congregational leadership too inbred.  It takes a while but eventually this Leadership Development Cloning Experiment yields its results.  They are left with worthy loyalists who tell each other how wonderful they all are while the human chaff floats around someplace else in the Jewish environment, adding to its entropy.

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.

Tapping Resources

As we transition from summer to fall, and the calendar moves to October, I reach the midpoint of my semiannual projects and the midpoint of my time on AKSE's Do Not Call List.  The six projects could have been further along by now but I regard myself as rather successful in exploring alternatives to a generally mediocre synagogue experience that resembles Hebrew School a lot more than it resembles college Hillel, the principal encounter that really cemented me to Judaism.  Hillel has transformed itself organizationally in the decades since I graduated.  Rather than providing a building for interested people to enter, they have become more assertive about sending shelichim around the campus, identifying friends and friends of friends who might benefit from participating in the programs, then inviting them to be absorbed into the group.  I will assume that the learning and worship that goes on there, at least at the larger places, has stayed at university standard in parallel with other university offerings.

Hebrew schools struggle, the one at AKSE becoming more suitable for a one-room schoolhouse than a multi-teacher enterprise.  Membership at synagogues is down.  I almost ration my own attendance to two shabbatot a month, that being my temperamental limit of Aliyah Sound Bites and Hebrew School facsimile, though it might be different if it were as welcoming as my hospital has been.  Yet as I explore Rabbi Schwarz Jewish Megatrends and Ron Wolfson's Relational Judaism and now Hayim  Herrings Tomorrow's Synagogues Today, I know there are better experiences to be generated and people on the sidelines willing to put forth the effort to generate them.  Accessing them without offending the people in place who indeed do a lot of work and think they are accomplishing more than they really are takes a blend of tenacity and finesse.  I'm good at tenacity.  Maybe the place needs a Cruise Director, that individual who assumes the responsibility for making sure that there are no spectators for the Line Dance.  It's one thing to have activities, quite another to want to be part of the pageant.  It is doable but it means thinking differently.

One approach might be that of IKAR a transdenominational enterprise in Los Angeles.  Everyone can come and watch but you cannot become a member unless you commit to some activity to engage in.  AKSE could do that up to a point and would be better off with tapping into talent as a requirement instead of depending on A-list invitations from the President.  Maybe my project would be to catalog talent, if I end up wanting a project.  Talent exists but it stands with me on the sidelines, either for not being asked or for being former talent that got slighted in some way.  Some upcoming chat with the visiting scholar next month.

YK Reflections

Our holiest day came and went.  Kol Nidre was not particularly well attended.  The sanctuary seemed more completely occupied the following day, keeping in mind that the portion devoted to seating has been reduced every few years.  We were asked for money a lot.  Mostly noble causes like keeping the synagogue solvent or supporting the infrastructure of Israel.  The reason for buying Israel Bonds was a lot more obvious than the reason for keeping the synagogue solvent.  One of the salient features that keeps AKSE different from Chabad is that AKSE has to adapt to its constituents while Chabad does not.  Keeping it solvent for the sake of keeping it solvent without keeping it attractive and vibrant as a consequence of keeping it financially viable might be a hard sell.  And there was a pitch for pet projects:  AIPAC,CUFI, multicongregational Israeli trip which seems unduly expensive, parsha class.  None of this really grabs me, though I do plan to study the parsha each week on yutorah.org, something I've not done in a few years.  Maybe Israel has become the new Holocaust, a purpose for existence beaten into a cliche by Hebrew School or Rabbis who want to turn their congregations into Hebrew School.  Of course it has its place, but so does the Parsha and so does the reality that CUFI while friendly to Israel also carries the banner of some very un-Jewish ideology that gets hidden, perhaps even a form of genevas da-as.  But throughout the YK observance, somebody on the bimah was trying to sell us something.  It all registered neutral, which is better than registering negative.

In my capacity as observer, there were some encouraging parts of the experience.  People of great talent occupied those seats, most of them capable of doing a lot more to enhance the congregation than they currently do.  Perhaps they would if anyone solicited their participation but for the most part nobody has.  If there is any legacy to the outgoing President, who has really worked hard on the congregation's behalf, I think it is that he surrounded himself with a small group of insiders that he knew he could work at the expense of creating a grass roots.  The role of committees has contracted, contrary to the advice of the consultant a few years back.  Appointments for key initiatives comes from an ever contracting pool.  The Nominating Committee has been thoroughly corrupted from a means of evaluating and expanding talent to a telephone squad for the President to decide who he wants to surround himself with.  That form of thinking has some very negative consequences for an organization that has thrived on its openness, some of which seem to be playing out.

And finally, the break the fast presentation was superb.  In addition to an outstanding display of food, they took advantage of a diminishing attendance to create a space with tables behind the sanctuary where people could help themselves to food and enjoy each other.  The people really are capable of excellence but sometimes you have to insist that excellence be consistent in all activities.

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.

Early Rosh Hashana

While the Holy Days being on the first of Tishrei from year to year, I tend to think more in terms of my customary secular calendar which tells me which days I am supposed to work and which I can stay home.  Summer begins on Memorial Day, ends on Labor Day, irrespective of astronomical realities.  The Jewish holidays are therefore perceived as variable.  When they come in early September, they sneak up on you relatively unprepared.

In my commitment to myself to function as an observer, I approach the New Year with a measure of detachment.  There are five people I'd like to greet from afar, and probably will by Hoshana Rabba.  And I really do take some account of misdeeds that should not be repeated.  I have greatly enjoyed Rosh Hashana services at the Merion Tribute House, a synagogue offshoot while the fast of Yom Kippur gives me some measure of accomplishment.  Relented from my non-participant status and agreed to do Shabbat Shuva Haftarah which I've not done in a while.

These days have become something of quiet time for me.  Schedules are flexible for the most part, but not absent.  In another era, the early arrival of the Holy Days would have me scrambling to complete greeting cards but they have largely succumbed to easier electronic communication.  Fewer on the receiving end as well so less of a display to tack onto the walls of the sukkah.  While attendance at the Merion Tribute House has been well subscribed, Yom Kippur attendance at my home congregation has atrophied from year to year in proportion to the membership attrition.  It has its predictability and maybe some people are inspired in some way from the experience.  At other places Rosh Hashana displays the real character of the congregation with people trekking to the Rehoboth Beach Outlets for discounted designer finery and machers parading up to the Bimah for their Aliyot.  A place where everyone who's anyone comes to be seen.  For us it is more of a chore to get through, busy season for the clergy and a few volunteers, but it does not stand disproportionately to other events of the year.  Sukkot quickly takes over followed by shabbos each week.  Our Board has a discussion of the Holy Days were received each year but like macrophages, they have no memory and the same experience will get carried over to subsequent years.  So will my relatively ingrained misdeeds.