Floating residents

I was talking to one of my interns the other day - she had a child in medical school, and is thinking about having another one - and she pointed out that our residency program (like many others, I imagine) has no maternity leave. Meaning: sure, you can have a child during residency, and no one will fire you for that (nothing short of killing patients will get you fired from a residency program, so desirous are hospitals of working diploma'd bodies) -- but you will have to cobble together your own leave, and it won't be any more leave than what is granted to any resident under our current schedule: namely, four weeks of vacation (two times two weeks) and several months of elective (still working, but pretty much nine-to-five).

On second thought, since employers are required to guarantee more maternity leave than that by law, I suppose our residency program is indeed guilty of failing to offer proper maternity leave. No one will take it to court for that reason, because residency programs have long enjoyed the benefits (and curses) of the twilight zone between educational establishment (students can work, and be made to work, as much as they agree to) and patient-care employer (subject to 405 regulations and all the rest of it).

If our residency program, and all others, were (made) to decide that they should offer proper maternity leave, in a block like other employers do, how would this happen in practicality? Two things would have to be true: residency programs would have to allow residents to finish in longer than the time customarily allotted to them; and "floater" residents would have to be available to fill in the gaps when others take leave. (You can't have residents in the same program fill in, as this would undoubtedly run afoul of work-hour regulations.)

Floater residents: why not? Our program hires moonlighting attendings, PAs, and all manner of other healthcare providers.

On Working With People Who Are Just Slightly Younger Than I Am

How old do you have to be before you no longer have to say "peace out" and "peeps" (="people," e.g. "patients": "Let's go down the list of your new peeps.")? Am I old enough to be exempt? I never got the e-mail.

On Having An Unasked-For Day Off Tomorrow

Thank you, Jesus, for giving our family this time together.

A Non-Profit's Molting Pains
The byuralistke speaks.

Yugntruf just changed its entire executive board and hired a new office manager. She's learning Yiddish as she starts her new job: her blog (in English) gives me some cause for optimism.

Not a haiku

I crave glass clear
to the other side, swimming
through the bottle
towards a reversed message:
HOLD WHOLE WORLDS
IN WAKING HOURS.

Semper septic

It's the damn inevitability of sepsis in the ICU which is so tragic and frustrating. It's like every patient's story has the same ending.

Long umbilical cords
and other poetical equipment.

"...room upon room of song, smell, death, and dance from the four corners and the mixed races of his family, and much else besides: from Jews to African-Americans to Poles."

More in H_NGM_N #7, and my review of Sean Thomas Dougherty's Broken Hallelujahs.

Frustrating idioms of the medical profession
First in an endless series.

"workup": tests, imaging, and the like which doctors use to analyze the cause of or prognosticate a given condition. "He had a full workup": the doctors did the tests they thought indicated. Unfortunately, when one uses "workup"without thinking, it can appear that all doctors agree what tests should be done, or that the tests are sufficient. "Had a cardiac workup" does not usually mean "exhaustively risk-stratify a patient for cardiac disease, determine its etiology, and plan for treatment," but rather "was ruled out for acute coronary syndrome [heart attack] or arrythmias."

That's first off. Second is the philosophy of medicine that "workup" implies: the body is a machine, lying there broken, and we approach with our tests to tinker until whatever broken part is repaired. Sometimes this philosophy is appropriate, but more often than not the patient is left dissatisfied after the "workup is negative."

Next up in frustrating idioms: "so we can see what's going on." ("Just get a CT scan of the abdomen so we can see what's going on.")

"Finger pads" in Spanish?
Ahora sabemos.

M. H. Graham just sent me a complimentary copy of her Ahora Hablo! Medical Edition, a handy paperback of Spanish terms useful for medical professionals.

It seems useful and relatively error-free (there's the odd typo, but no big deal). Had I seen it in a store, I would have bought it - it's only ten dollars. The most important feature of the book is that the words and phrases it includes are used nearly every day by many healthcare workers -- fun conversation starters like What color is your stool? and Do you have asthma? My Spanish is fluent (though not native) and I can testify that I've already learned a number of words from this book I didn't know before.

On the wrong side?

I realized just this year, perhaps later than everyone else, that I have been misunderstanding the entire* story in Genesis about the massacre at Shechem by Shimeon and Levi occasioned by the rape** of Dinah. I have always taken it as obvious that Shimeon and Levi did the wrong thing - that Jacob scolded them, and that their answer ("Is our sister to be treated like a harlot?") is self-righteous indignation. For the first time, I realize that the Chumash* does not disapprove of the actions of Shimeon and Levi. The reason Jacob says nothing after Shimeon and Levi's response is that he has lost the argument. The reason the Chumash does not disapprove is that God is on the side, here, of those who massacre the unclean.

*Putting aside for a moment the multi-authored nature of the Chumash, which I think is evident.
**If you think "rape" is the right translation - open to question.

The Lonesome Death of Max von Pettenkofer
From the American Journal of Epidemiology.

In the mid-19th century, the German hygienist Max von Pettenkofer viewed cholera as resulting from the interaction between a postulated cholera germ and the characteristics of soils. In order to cause cholera, the cholera germ had to become a cholera miasma, but this transformation required prolonged contact of the germ with dry and porous soils when groundwater levels were low. This hypothetical germ-environment interaction explained more observations than did contagion alone. Despite its attraction, von Pettenkofer's postulate also implied that cholera-patient quarantine or water filtration was useless to prevent and/or control cholera epidemics. The disastrous consequences of the lack of water filtration during the massive outbreak of cholera in the German town of Hamburg in 1892 tarnished von Pettenkofer's reputation and marked thereafter the course of his life. von Pettenkofer's complex mode of thinking sank into oblivion even though, in hindsight, germ-environment interactions are more appropriate than is bacteriology alone for explaining the occurrence of cholera epidemics in populations. Revisiting the fate of von Pettenkofer's theory with modern lenses can benefit today's quest for deciphering the causes of complex associations.

Trauma in the slot
Notes in and out of the ER.

Oh hell.

I put down whatever I'm doing, sometimes spilling it/surprising the patient/abandoning my computer orders uncompleted, and quick lope across the hall to the Trauma Slot (it's a room with space for several trauma victims), where I put on a disposable gown. Then I am supposed to shear off the victim's clothes and stick an IV in their arm. He (they're generally hes) is lowing, often drunk or otherwise substance-addled, but definitely in pain. I don't move fast during this ritual, nor in general, so a few minutes into the slot I'm standing uselessly at the side of the room, waiting for some signal from a superior to go get more work done inside the ER.

Back in the ER desperation on all sides: patients ask when you're going to see them, families wonder what's going on, why hasn't the X-ray been read/glass of water brought/IV taken out of arm/broken bone been set. Nurses are busy doing something else. Senior residents drift from corner to corner of the ER, occasionally assuming a stance ten feet or so away from the patient board on your end, with a look of quizzical impatience: why aren't things moving faster? Why hasn't N, with the abdominal pain, been seen yet?

Rounds punctuate. Someone is admitted - off our hands. Someone is waiting for dispo - a test, for example, to decide whether they'll stay or go. Attendings talk about patients right in front of them, in the third person.

But nevertheless (despite all these initiation rituals that I thought I left behind with intern year, but now as a second year resident I am submerged in again, on this my ER rotation) I am seeing pathologies I never laid eyes on before: the dinner-plate eyes of cocaine, the writhing appendicitis, the horrible pain of a cancer patient that knows (or doesn't yet) that it will never go away completely.

Always the crush of patients to muddle through (primary care medicine in the Bush era), always the disappointed person who hoped that their months-long back pain would be cured by a 4 am visit to the ER. And always, in the middle of all this, the cursed interruption: Trauma in the slot!

Liking the ER

Is a guilt-inducing feeling. I shouldn't like divorcing patients' immediate complaints from their psychosocial contexts. I am in training to be a primary care physician, after all. Primary care should be a lot more than making sure someone doesn't have a heart attack or doesn't have appendicitis (or a cervical-spine fracture, or a really bad pneumonia, or shaking-raving alcohol withdrawal). It should be about treating the whole person.

And that's what the patients think, too. As we know (and our president celebrates), many people come to the ER because they don't want to, or can't, find primary care anywhere else. Thus they step in the door expecting a holistic approach to their problems, while ER docs still cling to their theoretical model of Emergency as triage and immediate treatment.

I could wax abstract here about the difference between deep medical knowledge - holism - and goaltenders' medicine - blocking the bad stuff: each of these has its place. I could connect this to bekius vs. iyun: the long-standing Jewish yin-yang between knowing a lot of Torah and delving deep into it. But there's too much at stake here hour-in and hour-out to allow abstractions. Patients are to be triaged either upstairs or out the door, and few of them (at least in Bellevue) understand how they are to have their chronic problems addressed.

I liked my first day because I felt in charge and in control (though supervised and occasionally countermanded, of course). But, on second thought, I should have tried to grab on to whatever jagged outcroppings of social context I could find in every patient's primary complaint. I should have tried to act like a primary care doctor even while doing the ER triage dance.

Making a Minyan: Women in Tefillin
Famous picture - second thoughts.

As I looked at the picture over and over again, I felt used. I didn't see myself in it, nor my mother, nor the other women I knew. Instead I saw the photographer's projection of what women in tefillin must be like: angry.
[. . .] We looked, to me, like a caricature of angry, scowling feminists. I called it the "Scary Amazon Women in Tefillin picture." [. . .]

For me, davening in tallit and tefillin has never been about women demanding the right to engage in rituals that had been limited to men. To me, the tallit and tefillin are how Jews should pray, and I had never, until I saw myself in that picture, seen them as an act of feminist defiance. [. . .]

But over time, something unforeseen began to happen. I started to get angry. I saw the female professors I admired in college not get tenure while their male counterparts were promoted. I saw the Jewish community blame highly educated working women for a declining birth rate. I saw women who had entered the Conservative rabbinate struggle for acceptance and for equality even 20 years after that historic decision. I saw my friends have babies and struggle to afford child care. [. . .]

I don't think [the photographer] was somehow prescient in his portrayal of us. I certainly don't think that he was predicting my own personal disillusionment. While I still think that his photo doesn't capture the essential love of Judaism, of prayer, of God, of ritual -- whatever it was that had brought each of the ten very different women in his picture to take on the mitzvot of tallit and tefillin, I now recognize myself in that minyan of defiant women, and that is a terrible disappointment.

Rahel Lerner in Lilith, Fall 2007. The piece (not on-line) is well worth reading in its entirety, as is the companion essay by her mother in response to the same picture.

Super Jewish Historical Prediction Game, Extra-Exciting Medical Education Version
Or: Even on Saturday

Since this thread at Pensées de Gil is still inexplicably active, let me make a prediction.

If "shomer shabbos residencies" catch on within the Charedi community (the Modern Orthodox and the Conservatives really don't buy into this notion), within a short time (twenty-five years?) there won't be any primary care providers coming out of the community itself. When that happens, either the quality of primary care for Charedim will decline, or a sensible posek will discover a remarkable heter: since most internal medicine programs these days involve very sick patients (and lots of them!) for whom pikuach nefesh is always on the agenda during their hospital stay; and since not working on Shabbos would mean disorder for the medical care of that community, and since Jewish doctors are a desideratum for a Jewish community [just as every community should have at least some doctors taking care of it which share its assumptions] -- well, then somebody is going to have to try and save some people in the hospital, even on Saturday.

Blogging the ER

For the coming rotation - starting tomorrow - I'll be in Bellevue Hospital's Adult Emergency Services department.

Besides managing patients on one side of the ER, the part of my role I am most eagerly anticipating (this is why I got into medicine, after all) is cutting off the clothes of trauma victims. I need to buy shears.

The New York Times discovers Yiddish
Again.

But nicely.

Terror in the Patient Encounter

Like meeting any new person, stepping into a room for a first conversation with a new patient is horrifying and humbling. All the insecurities that I've tamped safely down inside - after somewhere between a third- and half-lifetime of adulthood - come to the fore again: will they like me? Will we fight? Will I get out of this with what I want? will they get out of this with my hide? theirs?

Sure I am altruistic, sure I am aiming for good here. But the baseness of human relations has to be gone through over again (at least that's my experience) in every sphere, even in medicine - or especially. When you're sick, and I am intruding upon your sickness to define and delimit it (in the biomedical conception), why shouldn't it be an adversarial meeting?

End of Summer

Have you ever waited out all the sweatdays
till you're again worthy
of fresh pane-dew
cool as a beer bottle:
stand outside
face against the window.

When fall has left
its cold shoulder to you
again you have to get used to
the zealous seasons.

Winter which snows over every argument.
Spring which greens away others' desires.
And summer which sparkles and smiles and dries
and kills.

The sneezer himself
Li-achoo-atcha kiviti.

"[Talmud Yoma 88a: the breath of life in his nostrils teaches us that the essence of life is in the nostrils.] That is to say, the essence of the distinction by which one knows if the person who seems dead is definitely dead, or if there is still some breath of life - if there is still some breath in his nose there is still the breath of life, and if not he is definitely dead. One should not rely on other definitions. The reason for this, it seems, is that a person's soul leaves him in the way which it came, and since it came first through the nose, as it says in his nostrils the breath of life, so too is its exit also through the nose.

"It's possible that this is the reason for the custom to say "Asuse!"[Aramaic: Health!] to the person who sneezes (see Berakhos 53a and Rashi there). This according to what is said in midrash Yalkut, parashah Lech lecho, which indicates that until Yaakov people did not become sick before death but died suddenly by sneezing - a person would sneeze and his soul leave through his nose. This is also because the nose is the transit point between life and death, therefore when a person sneezes he is exposed to danger, and people say to him "Asuse!" Rashi writes in Berakhos: 'People are accustomed to say Asuse to the person who sneezes.' That is, only other people customarily say this to the sneezer and not the sneezer himself. This also implies that this is but a custom. But the Yalkut there maintains that a person is obligated upon sneezing to thank God - apparently then the sneezer himself is required to say some words of thanks. There are those whose custom it is to say 'I hope for your help, God' [lishuoskho kivisi adoynoy]. Apparently this is then a obligatory custom. Possibly one can say that the sneezer himself is obligated, but for others it's only a custom out of politeness [derekh erets]. But I'm not going to go into this further."

--Borekh Halevi Epstein, Torah Temimah on the Torah portion Noach

Sukkah poster with Conservative gedolim

Is there one? Can somebody make one?

The Great American Yiddish Novel
Dead, true, but also . . .

aborning here.

Loneliness/Holiness
Resting on the eighth day.

I like our Diaspora's Shemini Atzeret, this shy orphan yontev. Rarely is it jovially nicknamed ("what are you doing for the Shmi?"). Its songs are stolen from contiguous holidays. Some people make a point on that day of sitting in the sukkah - because it's still Sukkot. Some make a point of not sitting in the sukkah - lest it get mixed up with Sukkot, because it's a holiday of its own. The uncertainty is charmingly Atzeretsian.

Come out from your cave, Shmi! We love you.

* * *

Even more interesting than the ongoing saga of How Dead Is Conservative Judaism (I guess it's hard to find a less interesting topic) is the tale of Arnie Eisen. This professor of sociology is now the de facto spiritual leader of the Conservative movement, meant to be the miracle worker of 3080 Broadway. This cries out for a superhero, The Sociologist-Rebbe (busy, Mike?):

Disciple: Oy, rebbe! Is this chicken kosher?

Eisen: Yankl, I find it fascinating that you are voluntarily submitting to my authority!

Monster Library Extravaganzas
. . . and other pop-culture phenomena, through Vilna Ghetto posters.

Like life, these Vilna Ghetto posters are not inspiring at first glance. Some of them could even be called uninteresting, the sort of thing we would pass on a busy Manhattan street without a second glance. A Hanukkah party, a lecture, a basketball game. But initial glances can be deceiving. First, many of these posters are handwritten (some with calligraphic skill); second, the great majority of them are in Yiddish, and third — and most important — the posters are the uppermost, visual layer of daily life in the ghetto.

More in the Forward.

Thirteen days late
and a few shekels too short.

Why - you might wonder - do American Jews, of mostly Ashkenazi ancestry but converted in recent decades to "Sefardic"* pronunciation, mostly say "Rosh Hashanah and Yom Kippur" rather than "-shanah" and "Kippur" (or "shanah" and "Kiper")**?

I wondered that too. But I have no idea. Any takers?

*Ashkesfardic.
**I know I'm supposed to use IPA. So [su] me.
***Where is Naomi Chana, anyway? I miss her and her footnotes.

Medical epistemology
Or: why doctors and patients think so differently.

I gave a talk yesterday on this topic at NYU's primary care residency program. The outline (together with a bibliography) is here. More later if interest.

Charedipedia for real

This site makes Yiddish Wikipedia look like a bunch of porkeaters.

Yet another DNR
Do Not Reimburse.

A recent article in the New York Times publicized changes in Medicare subsidies. In the article’s own words, “Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move [that] could save lives and millions of dollars.” This change was widely discussed, no less so in our hospitals.

But the devil is in the details. What is a preventable error? How was the list modified, and whose idea was this in the first place? What are the implications for our daily practice?

Learn more in Clinical Correlations.

You say you want to understand epidemiology?
1. Be skeptical. 2. Don't believe the results. 3. Wait for a randomized clinical trial.

If those three points aren't enough, read the latest in Gary Taubes's ongoing crusade to take epi down a peg.

Gay? Okay!
Apparently uncontroversially. And uninterestingly.

I love my shul but sometimes it drives me up the wall.

For instance, a recent letter (signed by the Chair, the President, and the rabbi) informs us of some recent deliberations of our Ritual Committee, which discussed "how [the recent] decisions of the CJLS [regarding homosexuality] would affect our membership criteria; and second [. . .] whether or not we would recognize and celebrate gay and lesbian relationships." The conclusions, unsurprisingly, are that "two adult Jews who are members of the same household may enjoy a joint membership" and that "we should publicly acknowledge same sex relationships in the ways we currently acknowledge married couples. This change would mean that a gay or lesbian couple could hold a commitment ceremony in our synagogue and be called to the Torah together in celebration of an anniversary." It is also unsurprising that "both recommendations were overwhelmingly endorsed" by the shul's governing bodies.

I agree with all this! This is all good, for reasons I think I've outlined before on this blog and which scholars have defended in the relevant teshuvot: in short, homosexuality is not immoral, halachah and morality should reinforce each other despite significant but temporary contradictions; and, just as the prohibitions in the Torah have been continually re-understood throughout the generations, our generation is bound to do the same. What drives me nuts is that none of these plausible reasons - no reasons at all! - are stated in the letter. Sure, our rabbi spoke about these issues from the pulpit, but now, when actual decisions bearing on peoples' lives have been made in our shul, would be the perfect time for a full-throated (re)statement of the principles our shul finds applicable in this situation - or, at the very least, why these recommendations were "overwhelmingly endorsed." What is it about gay and lesbian commitment which put it onto our shul's agenda? Do we think not recognizing such unions is a moral wrong? Then say it! Put some bite into the "overwhelming endorsement"!

I wonder if the way this decision might have been made in our own shul (I don't really know how it was made, since I wasn't at the meetings; I'm just speculating) might reflect how it might be made in the Conservative movement at large. There are two possibilities that come to mind. One is that the majority of Conservative Jews (who care about such matters at all) have already made their own intuitive halachic decision. Puk chazei: go and see what the people are doing, and what they are doing is failing to endorse the putative immorality of homosexuality or the eternal validity of toevahschaft. Second is that people don't really care; this halachah is something which was ignored, or taken for granted to be invalid in any case.

I much prefer the first option. In that case, I would welcome (again) an endorsement by our shul's leadership, that this change was taken for positive, halachic-affirming reasons and not merely as a drift down the stream of inertia.

Year out!
A message from Shawna Tova and Felix Anyo-Nuevo.

May your new year be modified by all the adjectives you yearn for.

Eschatology ho!
Elul concentrates the mind wonderfully.

I have been reading the ninth chapter of Maimonides' Laws of Repentance, with its differentiations among the various final chapters of our worldly existence. Maybe because the world at times feels well-nigh unraveled, there's not just one end of days but multiple: the world to come (where the righteous sit, crowned by the Divine radiance), which is not the same as the Messianic age. Per Maimonides (quoting the Talmud), the Messianic age is different from the present age in one particular only: the Jews' sovereignty over the Land of Israel.

"But we're there!" you might say. Not so fast. If you are in the mood to quibble, you might say that (a) the current State of Israel is not coextensive with the Land of Israel, and/or (b) the current sovereignty is not the same as the Kingdom to which the traditional sources refer.

But I don't quibble - not because I think the current political situation in Israel can be identified with malkhus ("sovereignty"), but because I don't think that malkhus is the criterion for the messianic age. Even if there weren't multiple opinions in the Talmud about what the messianic entails, I still wouldn't think such sovereignty is important enough to serve as the hook to hang the Messiah's hat on.

Certainly sovereignty is important (I'm enough of a Zionist to say that), but we need something else to convert the world-that-is into the world-that-ought-to-be, something basic and transformative. It doesn't seem like the return of Jews to our historical homeland, as positive and uplifting (and basic) an endeavor as this is, quite fits the bill.

How then will the messianic age differ from our own? (Providing one believes in such an age.) I don't have any neat answers.; anything neat enough to propose here would be flat and unsatisfying. But I agree with a friend of mine, Richard Claman at Town and Village Synagogue, who has said more than once in his lectures that Conservative Jews have been afraid of discussing eschatology - the end of the days. We have left that stuff to the fundamentalists, at our own peril.

The point he makes is this: when we teach our children about Judaism, we brainwash them. Clearly we think that the benefit of this brainwashing outweighs the downside of coercion. What is the benefit? Do we think that our Judaism will bring redemption to the world? a dawn of peace? does the Jewish people have a unique role to play, and if so, what? What is the malkhus which our Messianic age will bring?

Death and the sleepless resident

It turns out that work-hour regulations for residents do nothing one way or the other for patient mortality. (Or almost nothing.) I'm not sure what this tells us. Were work-hour regulations really instituted on the theory that this would directly benefit patient mortality? There are other indices, I think, which are more likely affected (patient-provider relationships, morbidity, error rate), even though they are harder to study.

Take two different patients who both die in their second week of hospitalization. Patient A is cared for by well-rested residents; patient B, by zombies. I think patient A received the better care by a number of measures, even if mortality-wise they're even.

Happy holidays!
Awe! Isn't that sweet?

I like this time of year because there are so many different ways of greeting someone, and I think I variously use all of them:

Happy New Year!
Leshana tova! [Ashke-Sfard pronunciation]
Shana tova u-metuka!
Leshone tove! [American-Ashkenazic, i.e. stress on the penultimate syllable]
A gut [zis, gebentsht, . . .] yor!
Leshone toyve [tikoseyvu]!

Add your own that I've forgotten, in this blog's famously rowdy and hyperactive comments section.

Charged with punishment: the Artscroll

Marc Shapiro, the Modern Orthodox historian, has an erudite, wide-ranging, and entertaining post over at the Seforim blog (thanks to S.); the conceit here is that Shapiro is trying to find mistakes with Artscroll. Buried in the middle is a nugget which points up (to me) why even Modern Orthodoxy can be difficult to understand.

Shapiro wonders how to translate אדון עולם, i.e. the first two Hebrew words of Adon Olam: "eternal Lord" or "Lord of the world"?

[ . . .] I was pleased when I found the perfect example of an Arscroll error, and this in a prayer that we all know well, Adon Olam. What do these words mean? To answer this, most people will open their Arscroll siddur. Artscroll translates, “Master of the Universe”. This, or similar translations (e.g., Lord of the Universe, Master of the World) seem to be standard. Yet for a while I was convinced that the proper translation was “Eternal Lord.” After looking at the song as a whole, and seeing how it speaks of God’s eternity, it appeared clear to me that this is what the first two words mean.

Agreed! And refreshing (thought I) to see recognition in Orthodox circles (okay, recognition by one Orthodox writer) of a text's plain meaning.

But it was not to be. In Shapiro's words:

A few weeks ago I received a letter from R. [Meir] Mazuz[, a Sefardi scholar], and well, let’s just say that I won’t be trying to impress people any more by pointing out that Artscroll has mistranslated Adon Olam. To begin with, R. Mazuz insists that Adon Olam is identical with Ribbono shel Olam. As for my point about “olam” never meaning “world” in the Bible, he writes:

זו דעת החוקרים האחרונים שעולם בתנ"ך פירושו נצח, אבל חז"ל לא הבינו כן

As proof for this he refers to Berakhot 54b

כל חותמי ברכות שבמקדש היו אומרים: עד העולם. משקלקלו הצדוקין ואמרו אין עולם אלא אחד התקינו שיהו אומרים מן העולם ועד העולם

At the conclusion of the benedictions said in the Temple they used at first to say simply, “forever.” When the Sadducees perverted their ways and asserted that there was only one world, it was ordained that the response should be "from world to world” [i.e., two worlds].

He also called attention to a passage in Sanhedrin 58b where the verse in Ps. 89:2, עולם חסד יבנה, is understood not as “forever is mercy built,” but as “the world shall be built up by grace.”

As I said, I am forced to conclude that in this case Artscroll gets a pass.

This is very frustrating! R. Mazuz seems to believe that the interpretations of Chazal trump pshat, even when other readings are more plausible and even (in this case) when the piyyut in question is post-Biblical, not to mention post-Talmudic! It feels weird, like Shapiro is being yanked back into line by the unseen hand of Orthodoxy.

Meaningless directions

If you have occasion to compose or think about your living will (and I hope you will soon), please do not include the phrase "heroic measures," which means nothing at all - or, rather, many different things to different people. One person's heroism is another's medical routine. If you would rather not be resuscitated (i.e. have your chest forcibly compressed and undergo electric shock), then say so. If you would rather not have a tube down your throat to aid in breathing, say that. If you would rather people not do "too much," decide what that means to you, and write that down - and tell the person you would like to make health care decisions for you if you cannot. Don't count on people understanding what you write unless you are painfully detailed and inescapably clear.

Presenting the second-year resident
Now in a magically supervisory capacity.

Said the cattle thief: it's time to take stock.

The intern is a snake devouring its own tail. The second-year resident ("R2" is the quasi-robotic nickname) is still chewing at her tail but is also keeping an eye on the tail-devouring of other snakes, with helpful comments all the while. "Open the maw a little wider! Fangs into the tail like you mean it!" And the hot sand all around, with the Georgia O'Keefe-ish carcasses. And the whistling of passing trains.

The meaning of the allegory: I still sometimes don't feel like I know what I'm doing, even with years and years - I mean, fourteen months - of medical experience under my belt. I know for a fact, more abstract than concrete and more intuitive than learned, that it is better to say "I don't know" than to invent a probably-misleading principle on the basis of limited information. But the latter is what I see people doing all the time around me, and whenever I say "I don't know," I still feel guilty and weak.

Some of this is due to lack of confidence, which will be repleted steadily until my graduation, at the end of my third year of residency. Some of this is due to epistemological uncertainty. I don't know what it means to know about medicine, and at times I'm not sure that everyone else does either.

Let me qualify: there are many models of what it means for a doctor to know something, but none of them covers all the situations that we encounter. "Evidence-based medicine" (one model) is a misnomer, because the "evidence" is population based, while much medicine is done person by person. There are many other jerry-rigged epistemologies, lizards skittering up and down the hospital hallways between the feet of housestaff. "See one, do one, teach one" - sure, but what is "seen" and "done" depend very much on how one is taught. Diagnostics is an epistemological minefield: take into account all your probabilities (Bayesian and otherwise), but you must still walk into a patient's room with at least two or three layers of information and attempted diagnoses made by other people in the hospital who have seen the patient first. Seasoned diagnosticians often cannot explain how they arrive at the correct diagnosis; on the other hand, autopsies (of a previous generation; these days they're rarely done) indicate that diagnoses are wrong about a quarter of the time.

The epistemologic dissonance par excellence is between doctor and patient. The doctor knows the patient's sick, and the patient doesn't believe this at all - or vice versa. The patient knows what's going on in her body, but the doctor needs to do another test to find out - because he says he doesn't know yet. You can say that this is because doctor and patient subscribe to different epistemologies (biomedical vs. traditional, quantitative vs. narrative, or what-have-you), or you can say that neither doctor or patient knows how they know things, or thinks about it much at all. (Meta-epistemology? You came to the right place.)

Now I'm a second-year resident, with more time to think about how I (don't) know what I (don't) know. This is precisely the time when I am supposed to start conveying my knowledge to those one step below me: the interns. (Many of whom, in terms of raw medical facts and figures, know more than I do anyway.) It's appropriate that I don't feel like I know how to do this.

Perhaps I'm thinking about this all wrong. Medicine (or, to term it more appropriately, health/sickness/wellbeing) is based not on knowledge but faith. Induction is a leap. The sun will rise tomorrow because we've seen it done so for our entire lives and heard stories about its constancy. Doctors and patients alike put themselves in the hands of their combined trust: standing at the foot of the mountain or at the door of the hospital.

Yiddish Week 2007
Reflections, 1.

I'm back from the Yiddish Week. The strangest thing is how normal we all are, we fringe Yiddishists, all the flavors of (mostly American) Jewry represented: the usual Reconservadox spread plus a Charedi couple; secular folks; old and young; couples with jelly-smeared kids. And it feels like (maybe?) that there are slightly more people with kids and 2o-somethings among us. On the one hand, speaking Yiddish should be normal for those American Jews that do so. It should be a choice on the menu with the respect due it - by no means the only one, but definitely a possibility. On the other hand, ideologies that seem normal are tame. We don't want to be stamp collectors, do we?

You look so drawn

Satisfactory Comics has a blog!

Fuftsik Sent and Madona
Yiddish rap in the Jewish state.

Check out this article in Yediot Acharonot. I haven't heard the sound files yet. (Thanks to reader MJ for pointing this out.)

Update: As usual, I'm about three to four months behind the curve -- the disk came out in May. I just listened to some clips. Lipa it isn't, just saccharine frumification of perfectly good music. (Why would you need an ultra-O version [track 5] of La Isla Bonita?)

(Speaking of Yiddish and Madonna, the new issue of Afn Shvel has a great article by Marc Caplan on Ms. Ciccone Ritchie and her practice of Kabbalah.)

Incrementalism versus single-payer health care reform
Different routes to the same solution.

Cross-posted to Clinical Correlations (with some edits there)

Health insurance positions: The obvious imperfections of our current health care system have inspired a number of solutions. They can be organized into two broad categories, incremental or single-payer. Each of these solutions is advocated by a single-issue lobbying group. National medical organizations support these solutions in greater or lesser measure.

Advocacy groups: Physicians for a National Health Program provides information about the benefits and practical implications of a single-payer health care system. The list of members of its advisory board includes their organizational affiliations, but (as its name indicates) the group is composed of physicians, not medical organizations or professional societies.

Incrementalism is represented by the National Coalition for Covering the Uninsured, a broad-based coalition of a number of organizations, including the AMA, the American Hospital Association, the American Public Health Association, the American Academy of Family Physicians, pharmaceutical companies, insurance companies and other organizations. Given the divergent range of interests and philosophies represented by this list, it's no surprise that the NCCU's plan involves a number of less wide-reaching improvements in the current system, including transparent pricing; personal Medical Savings Accounts; and the expansion of public programs to cover the very poor.

Professional organizations: Many medical organizations act as both professional societies and as advocacy (i.e. lobbying) groups. Their "home" positions may in many cases differ from their compromise positions hammered out in coalitions with others. The American College of Physicians, on its Web site, advertises its support for the Health CARE Act, a proposal which would increase federal matching funds to those states expanding Medicaid coverage to all those beneath the federal poverty level, and which would also provide increase federal funding to those states which increase coverage for uninsured children.

For its part, the American Medical Association "will strongly advocate for incremental measures to expand coverage," and in keeping with this advocacy is a member of the HCCU. In the long term, says its Web site, it will continue to push for the adoption of a market-based plan to expand coverage, "relying upon incentives and voluntary approaches." Similarly, the American College of Surgeons endorses universal access to care "within our current pluralistic health care system," i.e. to be incremental in the pursuit of change, with some features being implemented on a state by state basis. The ACS further emphasizes that "reducing health care costs [through improving information technology] is much more desirable than containing costs by rationing care."

Compared to other professional organizations, the American Academy of Family Physicians is full-throated in its advocacy of a plan to ensure health care coverage for all. On its web site, it lists those services which should be covered for all who reside in the United States (a relevant distinction in these days of proposed immigration reform). Assured services with no co-payment include prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; and evidence-based periodic evaluation and screening services. Other assured services, including outpatient physician services and outpatient prescription medications, would require 20% co-payment. The AAFP is also the rare organization which specifies a funding mechanism: a national, broad-based tax. Under the AAFP plan, coverage would be rationed by a "resource-based relative value system."

Differences and similarities: The differences in advocacy positions - taken on their own and as participants in coalitions - of the American professional medical organizations remind practicing physicians, and especially physicians in training, that the current health-care system can justify various solutions. Advocacy can also be modified in coalition for the sake of practical lobbying.

Personally, I think a single-payer system is the only solution that would fix the gaping inequities in our system -- but I also realize that there are many ways of getting there. PNHP might better fit idealists, and NCCU, realists, but they have a goal in common: reducing the numbers of the uninsured. Perhaps the coalitions can themselves coalition to put the problem of the uninsured higher on the agenda of the 2008 elections.

Mr. Hales and his medical husbandry

"The first person to measure blood pressure was Stephen Hales, an English clergyman of creative genius, who in 1708 directly connected the left crural artery of a horse to a 9-foot-tall glass manometer using brass tubes and a trachea of [a] goose." (from McGee, Evidence Based Physical Diagnosis)

Our Son Leaves His Fifty-Inch Plasma-Screen TV
Behind Because There Will Be
No Room in the Dorm

The remote control is eight inches long
with a display that I never understand
no matter how many times
you explain it: "Dad,"
you said, looking not at me
but the flitting basketball
and the neon cheerleaders,
"it's universal." So it
is. Then why is it only your Mom and me
who have to stare
at this blank Buddha
in our living room?
Its four sides
four years
times forty
thousand
dollars.

The narrative voice is bliss

At times the Gemara gets so intoxicated with its own line of thought that it just goes right ahead and ignores the Mishnah.

(d)(5) hold on a minute!
In this week's New England Journal of Medicine, Wendy Parmet provides legal justification for my inchoate worries. (More about the author.)

Many important questions remain [regarding quarantine and detention for tuberculosis control]. First, courts have not decided how long someone may be held before a hearing is offered or what procedures are necessary in the event of a mass quarantine. Courts have also not yet decided what probability of risk justifies short-term or long-term detention. Nor have they clarified what evidence is needed to determine that a person is or may be infectious or how infectious a person must be to justify isolation. Most critical, courts have not explained what must be shown to conclude that a patient is noncompliant so that detention is the least restrictive alternative. In tuberculosis cases, courts have upheld detention when a patient has failed, like [Andrew] Speaker, to follow medical advice. But they have not considered how forcefully that advice must be given or what, if anything, the government has to do to facilitate compliance. [. . .]

Compulsory isolation and quarantine alone cannot stop the spread of XDR tuberculosis. Moreover, excessive reliance on compulsory measures can lull the public into a false sense of security and at the same time prompt people who are at risk to do exactly what Speaker did — run. Fortunately, most persons infected with tuberculosis want treatment and have no desire to infect others. When clinicians and health officials work with patients and have their trust, most will cooperate. By ensuring that coercion is used only when less restrictive alternatives will not work and with due regard for the rights of those detained, the law can foster public trust, minimizing the need for compulsion and laying the groundwork for the comprehensive and costly control programs needed to prevent the spread of XDR tuberculosis and other contagious pathogens.

Dr. Zauberberg
Or: How I learned to stop worrying and believe in the (d)(5) hold.

I'm now rotating. (Of course, we're all rotating together, being on the Earth and all.) I'm currently working on the Chest Service of Bellevue Hospital. "Chest" means "lung" which means (at least for most of our patients) tuberculosis. There are lots of lung diseases, but the most common ones (pneumonia, asthma, COPD [emphysema and bronchitis]) get thrown in the same big barrel as all the other medical conditions, spread out among all the other medicine teams on the regular wards. This particular ward I'm on now is limited to the tubercular.

It is a Manhattan version of the Magic Mountain. There are New Yorkers of unexotic ethnicity (Puerto Rican, say) who have AIDS; there are Asian immigrants who have had the misfortune to contract drug-resistant TB; there are the elderly and demented from Coler-Goldwater, who are exiled from their residence until their cultures come back negative, no acid-fast bacilli swimming redly past the eyepiece.

And then there are those who are under arrest, under Article 11.47(d)(5) of the New York City Health Code. In other words: they have TB, and they can't or won't either take their medications or modify their behavior so as not to pose a risk of contagion; they have been warned, and now they are shut in. They are under (d)(5) hold.

This is justified by public health necessity, which is defined by the New York City Department of Health. On a case by case basis, the DOH balances the danger of contagion, the necessity of treatment, and the contingency of private circumstances.

I wish I had something wise to say here, something which would precisely trace this intersection so we could see it as clearly as pathologists see the offending acid-stained bacilli. All I can do - as usual - is ask myself questions while I immerse myself in the work the system requires of me in the name of the patients.

I've been thinking all day of the word "misprision," but I'm sure it's not as foreboding or relevant here as it seems.

The GH-2
A validated two-question happiness screening instrument.

1. In the past two weeks, have you felt hopeful, exuberant, happy, joyful, or energized?

2. In the past two weeks, have you felt pleasure from things which ordinarily give you pleasure?

If the answer to either 1. or 2. is "Yes," proceed with the full nine-question happiness screening questionnaire.

Queasiness of summer

Pressed in our book of estimations
a crumbled leaf.

The minimum gain through loss -

The first word my bell learns
is were-I.

A Louisvillian's dubious claim to fame

Crystal Meredith? Went to school with her.

Not that I agree with her suit.

What it's like to be an intern
A week before I unbecome one.

Resident: Says "Let's get a quick [arterial blood] gas."

Intern:
1. Sighs inwardly.

2. Goes and finds
a. a little syringe with some heparin in it so that the blood doesn't clot
b. some alcohol swabs
c. a Ziploc bag
d. another little syringe for a second try
e. needles to stick with

3. Goes into the patient room, lays supplies at bedside. Says: "I'm sorry, I need to get some blood from you."

4. Realizes that he has forgotten
a. Gauze
b. Some ice in the bag

5. Raises up the bed so he doesn't break his back.

6. Finds the pulse.

7. Gives the patient a considerate and well-meaning count-of-three.

8. Sticks the patient.

9. Doesn't get it on the first try [return to step 5], or the second, or the . . . ha! Gets it on the third try.

10. Holds gauze on the sticking point till the bleeding stops.

11. Takes the bag up to the lab.

12. Knocks on the door. Shouts "Hello?" Hears an echo.

13. Pages the person he's looking for.

14. Hands in the blood.

15. Waits by the computer, refershing the lab results page about twenty times till the results come back.

16. Hustles back to the resident with slip of paper in hand. "The gas [huff, puff] is seven point [whew] two three . . ."

Resident [absentmindedly]: "Hey, thanks! Yeah, I thought that's what it would be. Listen, can you just get some quick cultures off this guy -- and then guaiac him?"

What about stupid versus dumb?

Sage advice heard in the ER today:
"It's much better to be smart than intelligent."

I am distraught!

Gertel's closes tomorrow.

I will eat for comfort.

Justice, justice, shalt thou eat

A blog about the "social justice hechsher." (Hat tip to S.B. of Louisville.)

Avraham Burg: chauffeured hypocrite
And partial prophet.

Yes, Burg is a paragon of self-righteousness ("so attached to Zionism," wrote a commentator in Haaretz, "that he drove around with a chauffeur paid for by the Sochnut years after he left its employ"), but he makes many thought-provoking points about problems afflicting Zionism. (English here.)

NB: I don't at all agree with his misguided political analogies, and I don't think Israeli society is basically violent. But I do think Zionism suffers from weaknesses, and few other Zionists (or ex-Zionists) besides Burg are pointing these out with such uncompromising clarity.

Difficulty naming objects
. . . in English, maybe.

Neurology consult's note (about a Spanish-speaking patient of mine): "The patient has some difficulty naming objects. He calls eyeglass lenses 'crystal.'"
In other words, he calls eyeglass lenses cristal.

Random booksightings

I saw some interesting books at BEA. I also learned that asking politely "Do you have any samples?" will work only if (like my wife) your badge bears the name of a major book publisher, or if you are leadng a three-year-old by the hand and you are looking at children's books.

I saw:

Fotografiando las matematicas (a gorgeous album with depictions of "integral," "solid," and other concepts)

a volume of addresses by Sir William Osler, put out by Duke UP, of interest only because it demonstrated a tendency to hyperannotate a work which is actually not all that worthy of interest (e.g. the reader is informed helpfully that "Nicotine, Bacchus, and Aphrodite" refer to the vices of smoking, alcohol, and sex, respectively)

a book of problems in number theory from the training manuals of the Math Olympiad team from the U.S.

some fascinating Spanish-language poetry

Lineas Urbanas, a slim collection of essays in Spanish about New York City

a facsimile hardcover edition, pocket-size in all but width, of Les Fleurs du Mal with illustrations by Matisse

. . . but no Judaica, because I didn't get over to where it was

TB, Airborne
Traveling XDR class.

Now the truth can be told: if I were the other night intern, I would have been taking care of the phthisic traveler a few days ago. Even though I didn't have the pleasure of putting on a mask and going into his room in Bellevue (sorry, "a New York hospital," as the first Times article coyly put it), I feel compelled to provide some information about a question we're all wondering about: how easy is it to get tuberculosis on an airplane?

You can't do that experiment. (Though it would be fun!) What does the literature say? Google Scholar gave me links to two articles. One of them talks about TB transmission from an infected crew member to his colleagues. The other, by Kenyon et al., is titled "Transmission of Multidrug-Resistant Mycobacterium tuberculosis during a Long Airplane Flight." We read in the abstract: "In April 1994, a passenger with infectious multidrug-resistant tuberculosis traveled on commercial-airline flights from Honolulu to Chicago and from Chicago to Baltimore and returned one month later. We sought to determine whether she had infected any of her contacts on this extensive trip."

In brief, their findings were as follows:

1. The researchers managed to get in touch with 802 fellow passengers, or about ninety percent of the people on the airplanes the woman traveled on -- a commendable effort.

2. Of these passengers, twenty-nine tested positive on the "TB skin test." Twenty-two of these had previous risk factors for tuberculosis, which means it's impossible to tell in this case (since the passengers weren't followed beforehand) whether their skin tests were positive before they ever took that flight.

3. Of the seven without previous risk factors for TB, six were on the longest flight the passenger took (a nine-hour jaunt from Chicago to Honolulu). They all sat in the same section, and four of them sat within two rows of the passenger.

The authors conclude, "The transmission of [the TB organism] that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight, and close proximity of contacts to the index patient."

How does this article relate to the now-famous globe-trotting lawyer? The kicker here is that the woman in the article was "highly infectious". To wit:

The index patient was a 32-year-old Korean woman, who according to relatives was taking no antituberculous medication but had previously been treated for tuberculosis — twice as an adolescent in Korea and once within the past two years in Japan — with unknown medication. She arrived in Honolulu in April on a tourist visa and was reportedly coughing and lethargic while staying with friends (Household 1) for five days. She then flew from Honolulu to Chicago and from Chicago to Baltimore, where she remained with friends (Household 2) for one month. Members of Household 2 reported a worsening of her symptoms, including progressive cough, lethargy, shortness of breath, fever, night sweats, and the eventual onset of scant hemoptysis. In May she returned to Honolulu, flying from Baltimore to Chicago and from Chicago to Honolulu. Eight days after returning to Household 1, she had an acute episode of hemoptysis, described as consisting of approximately 1 liter of bright red blood. Hospital evaluation revealed extensive pulmonary disease (Figure 1), and her sputum was highly positive (3+) for acid-fast bacilli and was culture-positive for M. tuberculosis. The patient died of pulmonary hemorrhage and respiratory failure five days after being hospitalized.

She died of TB shortly after the flights in question, and was highly infectious when she flew. Contrast this with the patient in this week's story, who has so-called "active" tuberculosis (the organism is in his blood) but does not appear to be either symptomatically ill or highly infectious (the amount of TB-causing organism in his sputum is low).

Was quarantining the passenger in this most recent case (or, rather, attempting to quarantine him) the right thing to do? Probably, since he is infected with so-called XDR (extremely drug resistant) TB, which is associated with a higher mortality rate. It's best to be on the same side, even though it's probably unlikely that anyone he traveled with got infected.

(However, I'll take the opportunity to mention that many organizations (schools and the like) use the TB skin test indiscriminately, without assessing their members' risk factors for TB, their infectiousness if they do test positive, and the resultant small likelihood of transmission even if they are infectious.)

When I pray for certain sick people

it's not that I don't want other sick people to get better. Of course I'd like all sick people to get better.

So why not pray for all of them?

There are time constraints.

If you had infinite time, and knew everyone's name, would you include the names of all the sick in your prayers?

All the sick I know (of) personally. The farther away a sick person is from my personal knowledge, the less strength my prayers have. The less I really want them to get better. Or: the less often I think about them. It's a complicated relationship, if I were to think about it more precisely: not just the strength of wanting, not just the frequency of wanting, but the intensity with which the person's condition occupies my attention. The difference between home and another place.

Ideally, you would wish with equal strength for everyone to get better.

I think so.

You recite traditional Jewish prayers, which ask for the sick to be healed "among the other sick of Israel." Do you generally include non-Jews in this prayer?

Not generally. I don't know if that's because I know fewer non-Jews than Jews, because I tend to actively seek out (names of) Jews to pray for, or because I find it more congenial to include Jewish names in a Jewish prayer.

"More congenial" is a pretty term for racial exclusion.

Why don't we pray for the entire world? Why do we stick to our people, to our mythic ancestors, to our Jewish God? Because there's a power to specificity. If there were a strong prayer, embedded in a particular poetic idiom, which embodied a wish for the cure of the entire world, at once, without regard to any divisions at all . . . I can't imagine such a prayer because each prayer has its own preconceptions. Everyone wishes from somewhere, has their own family to yearn from. There is no universal person.

Why not write that prayer? Why not be that person?

There are cultural constraints.

An Intern's Lexicon
Version 1.0
Descriptive only. Not prescriptive, endorsed, or reflective of these terms' actual scholarly or humanistic meanings.

A-stick (v.) to draw blood through puncturing the radial artery.

Baseline: at baseline (adj.) Describing a usual or healthy state before arrival in the hospital or before some insult or incident. "His baseline mental status is poor."

Code: 1. (v.t.) To attempt to resuscitate a patient. (n.) An attempted resuscitation. 2. (v.i.) To undergo an attempted resuscitation. 3. (v.i.) To die after an unsuccessful attempted resuscitation. 4. full code (adj.): Someone who is to be resuscitated in case of cardiopulmonary arrest. Opposite of DNR.

Cute: (adj.) Possessed of some attractive or positive attribute. Used of older patients. "That patient of mine in the step-down is so cute! He sits there with his blanket, reads the paper, and asks me how I am when I pre-round on him in the morning."

Dispo: (Short for "disposition.") (n.) Plans for discharge, or a patient's destination upon being discharge. "She's hanging out, waiting for dispo."

DNR: Short for Do Not Resuscitate.

Fail: (v.) (paradoxical reverse construction) To be unsuccessfully treated by a medication. "That gomer failed Vanc[omycin], so we put him on Imi[penem]."

Female: (n.) Woman.

Fix: (often jocular) (v.) To treat, especially acutely. "Your list is so small!" "I fixed everybody."

Gome: Short for "get out of my emergency room." Originally used in House of God, now generally used. n. An older, chronically ill, demented patient. -- Gomey (adj.)

Hang out: (v.) To stay in the hospital while no longer acutely ill. "Anything going on with Mr. Smith?" "He's just hanging out."

Ins-and-outs: Measurements of intake and output on the part of the patient.

Jeopardy: (n.) A backup system whereby certain residents are called in when others become sick or otherwise unavailable.

Male: (n.) Man.

Mental status: (n.) Cognition.

Psych issue: (n.) Psychiatric, psychological, or emotional complication. More generally, any expression of feeling.

Resp (v.) : Short for "respire." To breathe at a certain rate. "The patient is resping at 36."

With it: (adj.) Able to converse; interactive. "He was with it when he came into the hospital

Say It In Chabon
Or: Der yidisher polislayt-unyon.

The newest, baroquest Jewish novel is one I won't be reading -- not because I am opposed to it on principle but because my complexes will get in the way of any purely literary experience. To explain we have to turn the clock back to 1997 (or sometime before), when Michael Chabon happened upon the sublime little volume Say it In Yiddish, a book that provides practical phrases for the traveler to Yiddish-land. The notion of a country whose inhabitants might use Yiddish in daily life captivated Chabon with its otherwordliness, and -- so inspired -- he wrote a whimsical essay for the Library of Congress magazine Civilization about such a land (with, it bears mentioning, the requisite Ben Katchor illustrations for a Yiddish reverie).

Thus ensued a kerfluffle in the tiny on-line Yiddish world, or, more precisely, a flame war (which I took part in) on the Yiddish e-mail list Mendele, most neatly summarized by Chabon's response to his critics (thanks to Leizer Burko of yiddishland.googlegroups.com for digging this up):

Date: Sun, 29 Jun 1997 10:05:37 -0700 (PDT)
From: Michael Chabon <mchabon@earthlink.com>
Subject: Weinreich's phrasebook

I am hesitant to wade into this fray, but the recent assertion by Mr. Mordkhe Shaechter [7.025] that "the author of that article has already apologized to B. Weinreich" compels me to step in. I have been following the recent exchanges over my article in Civilization ever since an interested party began forwarding them to me last week. They can, as far as I can tell, be divided among those who got it, those who most decidedly did not, and those, like Mr. Turkel [7.024], who feel qualified to comment without having read the article at all. Since I can neither speak nor read Yiddish in any but the most rudimentary fashion, I don't know what Mr. Adam Whiteman had to say.

People who get the piece recognize, first of all, that a book which explicitly advertises itself, on the cover, in capital letters, as a PHRASEBOOK FOR TRAVELLERS, naturally, logically, and commercially implies the existence of a country to be travelled to. A country. An entire nation. Not a neighborhood like Crown Heights. Not the annual meeting of a Yiddish language society or a Folksbeine. No one takes a Chinese phrasebook for travellers to Chinatown or a Chinese New Year's Parade. Even if someone might, such certainly would not be the imagined market for a series of traveller's phrasebooks.

This inherent implication is the central pillar of my ruminative essay (not a book review, not an analysis of the current state of Yiddish). There is a phrase given in the book, with Yiddish translation: Where can I get the boat/ferry to --------? My essay simply tries to imagine different ways to fill in that blank (that is, to imagine a place where one takes a ferry either to or from a country whose principal language is Yiddish). _Now._ Post 1958, when the book was published. Not in the twenties during some shortlived Soviet republic. Not in Israel shortly after its founding. But now, when the book, with its series of useful phrases for visits to auto mechanics and airline ticket offices, is still apparently very much in print. Where, in 1997, could you go that it would behoove you to know how to say, in Yiddish, "Which way to the casino?"

The second thing people who get the piece recognize, I think, is that however many people are still reading, speaking, and enjoying Yiddish, and however many young people are taking up the study of the language--however vital is the spirit of Yiddish revival--something has been lost. Something immense and profound. I don't know anything about Mendele and its ways. Perhaps this statement will bring the wrath of the entire subscribership down upon me. But I believe it. If this causes some of you to pity me, or shake your heads, or even wish, with Mr. Turkel, to excoriate me, so be it. There is no nation to take the Weinreichs' little phrasebook to; for every other language in the series, such a country exists. That difference saddens me.

In the course of a recent, and personally frustrating correspondence with Ms. Beatrice Weinreich, I did express my apologies to her--but not, as Mr. Schaechter seems to imply, for what I wrote. I stand foursquare behind every single word of that essay, without apology. What I regret is the hurt feelings and grief that my words evidently brought to a woman whose work I respect. It was a harsh blow to her to discover that someone thought her phrasebook was, among many other things, and in the saddest way, funny. (I gather from this list that I am not entirely alone in thinking so.) I have tried to explain to Ms. Weinreich that she, like some members of this list, had misinterpreted both the spirit and the letter of my essay. I love Yiddish. I love being Jewish. I love language and humor. All of these inspired my writing. The desire to hurt, offend, or insult Yiddish scholars and lovers of Yiddish did not make up even one atom of my motivation. My only desire was to report faithfully how the book made me feel, and the fancies it conjured in my imagination.

In her initial letter, and in her subsequent, generally unmollified reply to my reply, Ms. Weinreich argued, as have some members of this list, first of all, that the book could be useful for trips to Crown Heights or Williamsburg, for example; and second, that it might come in handy in Israel, or perhaps would have come in handy in Israel at an earlier time in the book's life. My principal rejoinder to these arguments has already been made: a phrasebook for travellers implies a country whose principal language is that of the phrasebook. Sure, there are, or could be, exceptions to this. There could be a phrasebook for travellers in Romany, say, that might be useful under certain conditions, or one in Latin that might at some time have come in handy in the Vatican. With regard to Israel, and the argument that there were or are many Yiddish speakers there who, as Ms. Weinreich attempted to convince me, felt or feel at sea in a land of Hebrew, I fail to understand how they would have benefited from an English-Yiddish phrasebook. Yiddish-Hebrew, perhaps. As for the English speaking traveller, if I had been going to Israel in 1959, say, I doubt I would have chosen an English-Yiddish phrasebook to be my companion.

AIl this is, however, completely beside my point. I wasn't interested in writing about whether this book was, or could be, useful; it is evident to anyone not blinded by sentiment or passion that such a book is, in a practical sense, all but useless. What interested me was imagining another world in which a Yiddish phrasebook for travellers would have an obvious referent, one with the official passports, customs agents, airlines, and ferry companies that play such a prominent (and, to me, poignant) role in the phrase book. The more I thought about, and imagined this country, the sadder I felt at its absence, a sadness which --for me, the only person I ever claimed to be speaking for--no amount of extinct Soviet republics, Chasidic neighborhoods, and Yiddish preservation and renewal societies will ever completely abate.

I'm sorry if this angers, hurts or irritates some people, or everyone who reads this post. I'm sorrier still for anyone who can't see the humor--the heartbreaking, wistful, uproarious humor--in the book. But I don't regret a word of what I wrote. On the contrary, Mr. Schaechter.

Michael Chabon

And from such an exchange, it turns out, came the impetus for The Yiddish Policemen's Union.

Ten years after the mini-dispute, I, like Bina Weinreich, remain unmollified. I see the humor of the book (which has acquired near-classic camp status in some circles), and I appreciate the whimsy of Chabon's take, but ("blinded by passion or sentiment," perhaps) can't overlook his mistake: the assumption (so American-Jewish! so confidently ignorant!) that only languages with a country have a useful function, that only official state languages have any business arrogating to themselves any practicality (except for the two non-state languages of Romany and Church Latin [!]). That's an ignorance that even a brilliant prose style can't wash away, and whimsy can't cover up.

Here I am, still blinded in Yiddishland.

Elinor Nauen on Roberta Oliver

I promised Roberta that I wouldn’t say she was brave. I promised Roberta I wouldn’t say she “fought the good fight.”

Well, RO, I lied. I am going to say that to the end she stayed considerate, gallant and gorgeously courageous. Part of that was her usual modesty: She never said “why me?” She believed she’d had a good run, and she was at peace.

But Roberta was, of course, far more than her cancer or her death.

Our friendship began about 10 years ago, when I was just starting to get involved at Town and Village. We’d both been invited to a dinner, where I didn’t really know anyone. (To appreciate this anecdote, you have to know that I’m originally from the Midwest.) So, we were at this dinner, and she was telling a story, rattling along a mile a minute: TWO miles a minute.

And I said, Hey slow down, I can’t understand what you’re saying, you’re talking so fast.

And without missing a step, in that 1940s wisecracking-dame voice she had when she was still a smoker, she said, What, they can’t listen so fast out there where you come from?

A couple of years later, I happened to drive her and her son to Binghamton when he started college. What I remember most about that trip is the way she talked about Torah. Her infatuation (as someone called it), her joy in and mastery of the technical details, her passion and commitment inspired me to want what she had. If I am a halfway decent Torah reader, it’s in large part because Roberta “tortured” me—by which she meant that she refused to let me or anyone else do a sloppy job, not if she could do anything about it. She was endlessly patient in listening to me and many others practice our reads—and she never missed a mistake.

Roberta would be the first to say she didn’t have a beautiful voice, but when she leyned, her voice was radiant. Radiant and beautiful, out of love.

She loved being Jewish. She loved kirbys and The Gilmore Girls and salami. She loved shopping—and returning everything she bought the next day. And she loved her kids. How many times we would be on the phone and she would say, gotta go, it’s Paul. Or, It’s Katie! She lit up each and every time she said their names. How tender Paul and Kate have been under the recent stressful circumstances. How much I admire them—and their mother for raising two such wonderful young people. As well as Roberta’s magnificent mom Sarah, who started it all.

Roberta gave the best gifts, not only because she was generous, but even more, because she paid attention to her friends and knew what would please us. She was organized—I don’t know how the morning minyan will manage gala ads and the summer beach outing and daily Torah reads without her. She was fun and a good dancer.

But like any friendship worth its salt, ours was mostly a day-in day-out accumulation of listening, talking, hanging out. It’s not anecdotes or witticisms I will miss about Roberta, but the everydayness of our friendship. The privilege of her love and friendship.

Roberta (Rivka bat Avi v'Sarah), ז"ל

My friend Roberta died Wednesday night. She used to read Torah every week at our shul. She was careful with every word, every last trope -- and she never failed to bury an excellent reading of hers under a mountain of self-criticism the minute she came back to her seat ("I completely missed that zakef gadol!"). She demanded a good keriah from herself and others. She would fume and mutter under her breath when the gabbaim were not doing their job with the more error-prone.

She had been sick for a while; she wasn't old at all. Her mother will be at her shivah. And this is what I'm thinking: זו תורה וזו שכרה? -- this is the reward of the Torah?

Me and Jerome G.
Making your doctor better.

Jerome Groopman: "Because we doctors see so many people, thinking in the moment, we have to use shortcuts. If lay people become educated about how we think, with a few appropriate and directed questions, they could help us think better. They should ask, “Could this be anything else?” or “I’m worried this is something serious.” That is the genuine partnership."

See my Q&A in this week's Forward with the author of How Doctors Think.

Disclaimers apply
And modesty! Lots of modesty.

It's not that I really think I'm the best overall Jewish or Israeli blogger, but you might as well vote for me, since someone was nice enough to nominate me. (Please also vote for In Mol Araan as best food blog and Katle Kanye as best non-English blog. All nominees in these categories here.)

Happy birthday, Itzik!

I had fun at Itzik Gottesman's 50th birthday party last night, held at the Yiddish Artists and Friends club on East 7th Street. (He's the assistant editor at the Yiddish Forward, also an ethnologist and many other things besides.) The music was great, the dancing -- well, I tried to, a little bit, and then realized it was way too complicated for me. Let me say something else about the klezmorim: you should go buy The Broken Tongue, Daniel Kahn's CD of Yiddish-klezmer-funk (or, as his band's site puts it: "Alienation Klezmer Bund = Radical Yiddish Song + American Gothic Folk + Punk Cabaret + Klezmer Danse Macabre = Verfremdungsklezmer Bund."). Also, Adrienne Cooper's daughter can wail the guts out of a song. (I know she has her own name; someone told me but I forgot.)

While I'm mentioning Itzik, you should read his article in the Forward from a couple of weeks ago about how the Forverts is adapting to the changed (i.e. mostly Chasidic) Yiddish landscape.

Avrom Sutzkever: the blog
Not by him but about his work.

First post, with my translation of "Ode to the Dove" (part I).

Earlobes

On Leviticus 14:14, Rashi (or the Rashi found in many chumoshim my chumesh) uses a word קנארפעל knarfel to gloss תנוך אוזן earlobe. I have no idea what kind of word this is. I don't think it's Yiddish, unless it's a weird rhoticizing way of spelling קנאפל knafl heel ("heel of the ear"?). If anyone knows, that would make me less mystified, and would save me the effort I'm currently expending in trying to look it up. (Ideally I would find a reliable critical edition of Rashi which includes the "Yiddish" glosses, but I don't know where that would be.)

Update: The lobe thickens. I followed S.'s advice and just spent way too much time browsing Google Books (thanks for nothing!). Jerold Frakes' Early Yiddish Texts 1100-1750 (see page 1 in Google Books) includes a few pages on the Yiddish and Tsarfatic glosses found in Rashi. Leviticus 14:14, and knarfel, are not among them. I guess then that whatever manuscript my bal-chumesh was working from either (a) had a later addition of this super-gloss, or (b) the publisher just stuck it in. I have yet to look at the printed Rashi manuscripts available through JNUL.

A conversation with a taxi driver

Driver: What language are you speaking to your daughter? Is that Dutch?

Me: Close! It's Yiddish. A Jewish language. Say [noticing Driver's accent], where are you from?

Driver: The Congo.

[. . .]

Driver: I love the Jews.

Me: Oh . . . !?

Driver: My King is a Jew.

Me: (thinks) Congo. Does Congo have a king? I know something awful is happening in Congo right now but I don't remember what. Was "Belgian Congo," right? Was there a king then? Belgian Jews? (says) King?

Driver: My King, who I love.

Me: (light dawns) Oh . . . Jesus?

Driver: Yes. I think the Jews are wonderful. You are so good with money!

Me: I wish I was.

Driver: You are born smart. You are blessed.

Me: Um . . . thanks!

Yiddish junkets

Brandeis, or . . . Birobidzhan?

Hamiltonians
are sometimes funny.

Thinking about thinking about medicine
Rx: Think better.

I recently had the opportunity to interview Jerome Groopman for the Forward on the occasion of his new book, How Doctors Think. I hope the Q&A will appear soon. Meanwhile, enjoy this discussion in Slate which is rather less polite and chummy than ours was. Perhaps I should have said to Dr. Groopman what I was thinking, which is: Research on the patient-doctor interview has been accumulating for the past twenty-five years; why are mainstream MDs discovering it only now? (It's also interesting that the Slate discussion does not touch on doctor-patient communication at all. Groopman: doctors need to be trained better! Sanghavi: systems need to be more effective! But, guys, getting the patient to tell the doctor what the problem is? This is simple? This is done to perfection inside the office?)

Annoying Hebrew slang
Courtesy of Eurovision, Teapacks, and Iran.

I recently heard Israel's entry to the Eurovision song contest, a Teapacks song called Push the Button (video, lyrics). It's a good thing the lyrics are available on-line, because I can't understand the words to most songs in English, much less in rapped Hebrew. I think I learned a new word:

שוטרים וגנבים מתרוצצים עלי
והם קופצים עלי, מתקרצצים עלי

Shotrim veganavim mitrotzetzim alay
Vehem koftzim alay, mitkartzetzim alay

This is translated somewhere as "Cops and robbers run all over me / And they're jumping on me, getting on my case." I didn't know the word מתקרצץ, but judging from chat groups it means something like "annoy, suck up to, give too much attention to, glom onto" (e.g. כשחיפשתי דירה בבית הסטודנט, התקרצץ אלי איזה זקן -- "when I looked for an apartment in the student house, this old guy started getting in my face"; or המלצר ששירת אותנו התקרצץ עלינו בצורה דביקה במיוחד -- "the waiter who served us glommed onto us in a really sticky way").

Where does it come from? My father read to me over the phone from Milon Slang Makif, Comprehensive Dictionary of Slang, by one Rosenthal, which connects it to the word קריצה, meaning "winking, blinking." (Interesting that the Milon defines the reflexive - hitpa'el - as "to be annoyed," while on the basis of Internet usage, and from the Teapacks song, the hitpa'el functions here as an intensifier - to annoy.) Presumably קרצץ is formed by duplicating the last letter of קרץ. (Google doesn't know much about קרצץ.)

Rosenthal's Milon Slang Makif connects the word to קרציה tick. (Thanks to Balashon and an anonymous commenter for corrections.)

And k-r-tz (קרץ) is a well-known root from Tanach and modern Hebrew. In modern Hebrew it means "blink" (as mentioned above), but Rabbinically and Biblically the word also encompasses "pinch, cut; snap [the fingers]". Here's where I should get off the train and let Balashon, with his greater knowledge and fuller bookshelves, drive the etymology forward. Or is that backward?

Liberal "Torah Judaism"
Much as I hate the term.

Is there "da'as Torah"? Are there scholars lay, rabbinic, or talmid-khokhemdik who immerse themselves in the Torah so completely that their system of reference is different from others'?

This is plausible -- with a caveat. These learned Jews aren't to be found just in the ultra-Orthodox streams of Judaism which have popularized the term. Even liberal Jews can have daas Torah. It's just that their -- our! -- Torah is different (cf. "seventy sides/faces/tongues/languages to the Torah").

After the blood and the lamb: beets

I welcome your envy: among the guests at our second seder was Ms. Chocolate Lady, with escort Mr. Lady-to-be. She made us chocolate mousse which is quite possibly the best thing I have eaten ever. Even tastier than the Jewish madeleine, I mean the afikoymen.

She also made us some beets, and I brought them for lunch to work today, a big tupperware that I meant to eat only half of. Big mistake, thought I, as I opened the plastic bag and saw a pool of beet juice on the bottom - now I'll have to eat up the whole thing so it won't leak into my backpack on the way home. So, worried about beet overdose, I started in. And they were delectable. There I sat, waiting for my patients to arrive, tie untucked into shirt, slurping up huge tasty beet hunks with trusty chunks of matzo. I was a beet-scarfing animal. I was a beet plague. I finished it all and I wanted more.

Lucky the door was closed. And I sanitized my hands before examination.

Meritorious mothers
From Solomon Schechter, Aspects of Rabbinic Theology, chapter 12.

The Zachuth of the pious ancestry may generally be described as the זכות אבות (the Zachuth of the Fathers), but the term Fathers is largely limited in Rabbinic literature to the three patriarchs, Abraham, Isaac, and Jacob, God's covenant with whom is so often appealed to already in the Bible. The Rabbinic rule is, "They call not Fathers but the three (patriarchs), and they call not Mothers but four" (Sarah, Rebecca, Rachel, and Leah) [1]. The last statement with regard to the Mothers suggests that there is such a thing as the זכות אמהות (the Zachuth of the Mothers). This is in conformity with the Rabbinic statement in reference to Lev. 26:42 regarding God's remembering his covenant with the patriarchs, that there is also such a thing as the covenant with the Mothers [2]. In another place, they speak even distinctly of the Zachuth of the Mothers, "If thou seest the Zachuth of the Fathers and the Zachuth of the Mothers, that they are on the decline, then hope for the grace of God." [3] And it would even seem that they would invoke the Zachuth of the Mothers together with the Zachuth of the Fathers in their prayers on public fasts prescribed on the occasion of general distress [4] . . .

[1] Berachoth, 16b. See, however, D.E.Z., ch.1, where they speak of seven Fathers who entered into a covenant with God. In Sirach (heading to c.44), the expression Fathers is even more extensive.
[2] T.K., 112c.
[3] See Jer. Sanhedrin, 27d, and Lev.R., 36,6. Cf. commentaries, and see also Cant.R., 2,9.
[4] See Pseudo-Jonathan to Exod. 18:9 and Mechilta, 54a. In our liturgy, the invocation of the Zachuth of the mothers is very rare. A Piyut (hymn) by R. Gershom b. Judah, recited on the eve of the New Year, has a reference to the covenant of the Mothers.