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.