“The oddity of physicians’ insistence that patients follow doctors’ orders”

By the fourth sentence of the preface to The Silent World of Doctor and Patient, Jay Katz has quietly issued a startling challenge to a fundamental principle of the doctor-patient relationship. He writes:

It took time before I appreciated fully the oddity of physicians’ insistence that patients follow doctors’ orders. During my socialization as a physician I had been taught to accept the idea of doctors’ Aesculapian authority over patients. When I began to doubt this authority, that was the moment when the book began to take shape in my mind.

“The oddity of physicians’ insistence that patients follow doctors’ orders” – the phrase brings you to an abrupt halt. Jay Katz, who wrote those words in his landmark book published nearly a quarter of a century ago, died in late November at the age of 86.

--Michael Millenson at the Health Affairs Blog. Times obituary of Jay Katz here.

Ill-Suited for Rapidity

Today's hospitals are all about the Rapid Response Teams.

But I was born a member of the Languid Deliberation League.

The Times Again Re-Discovers Yiddish

A whole article in the Times about Yankl Ejdelman without mentioning Yugntruf. Still and all, it's a positive piece.

But I can't help myself. Why is Yiddish a "venerable tongue" in the headline? Surely the language is no older than English? And why is it called "the 1,000-year-old amalgam of Hebrew, German and assorted European dialects that was once the lingua franca of Europe’s Jews"?

Amalgam? (You mean, perhaps "language"?) Assorted European dialects? (Maybe "languages"?) Lingua franca? (Rather, "first language"?)

It's almost as if the reporter knew nothing about the topic she was writing on!

Naw.

A conversation on the Lower East Side

[regarding me, between two Jews]

"Iz er a yid?" (Is he Jewish?)

"Avade iz er a yid." (Of course he's Jewish.)

What was next said, as I first heard it:
"Er kikt oys vi a narisher." (He looks like an idiot.)

I said "Vos?" (What?)

"Ir kikt oys vi an arisher." (You look like an Aryan[?].)

"Vos?"

"Vi an arisher!"

"Ah!"

Oh! I get it. Like an "ayrisher" ("Irisher" in non-"YIVO" Yiddish, Irlender in standard Yiddish), in the speaker's pronunciation - "arisher."

Thus was I saved from getting in a fight with two older men on the Lower East Side (probably avoiding a beating in the process).

Dr. Faust, meet Dr. Dewey: constructing a philosophy of medicine for the 21st century

Ultimately, because of vast historical and social forces, physicians by and large remain oriented towards an unattainable and inappropriate positivist ideal, and thereby severely compromise the deeper values of their own moral agenda. This choice—encouraged by the professionalization process—largely explains why medical ethics serves such a minor role in medical education; why complaints of medicine’s dehumanization are rampant; and why myriad studies, surveys, and testimonies attest to the lack of physician empathy. Indeed, if medicine aspires to an objective ideal at the expense of its unique value-laden agenda, the profession will be hounded by complaints that it has forsaken its ancient calling for a Faustian pact.

A self-conscious moral epistemology—an epistemology that remains aware of its ongoing negotiation of competing values and construction of its interpretative knowledge—provides a philosophy of medicine for the doctor’s diverse roles and activities. On this view, a philosophy for medicine must acknowledge the multidimensional character of medical thinking that utilizes values spanning the ideals of laboratory science to the empathetic response of humane care. But more, this philosophy must recognize a fundamental difference between the scientist’s search for the real and the physician’s pursuit of the therapeutic.

Medicine requires more than “true” outcomes (as in scientific truth-seeking); physicians embrace “best” results for the care of their patients. While seeking the “true,” patients and their caregivers are often satisfied with something else (for example, the effective intervention may be a sham treatment or a placebo). “Truth” directs clinical science, and clinical science directs itself to good outcomes, but in the hierarchy of medicine’s philosophy, it is ethics of care that directs the physician’s science and ultimately determines clinical choices.

--Alfred I. Tauber, Medicine and the Call for a Moral Epistemology, Part II: Constructing a Synthesis of Values. Perspectives in Biology & Medicine Summer 2008; 51(3).

Of minimal interest

I updated my literary CV. Where can I tell people that if not on my blog?

Lay down your scalpel, it's nap time!

E.B. Solomont (formerly of the Forward, as it happens), writing critically in Slate about the Institute of Medicine's work hour report, observes hyperbolically

Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it's nap time.

Solomont doesn't know that surgeons often must hand off care during a long procedure (colectomies can last forever)?

The Royal College of Surgeons (one of the organizations named by Solomont as opposing stricter work-hour regulations) provides a summary of their recommendations regarding training modifications. After a thorough review of work patterns in the context of impending regulations (or after they had already been instituted; it's not clear to me), the following findings became (magically?) apparent:

• a significant reduction in the need for acute surgical intervention (except for life- or limb-threatening conditions) between 22.00 and 08.00
• the majority of work undertaken by surgical staff during this period relates to the management of medical co-morbidities

Do you think that these shocking facts would have made themselves known without the threat of regulatory penalty?

The report also mentions a number of possible solutions. Leaving off for a snooze during the middle of a heart bypass is not mentioned, but scheduling innovations are.

Surgery and medicine training programs are naturally going to squawk at work hour regulations, and it's a tradeoff between continuity of care and well-rested residents. But it's also a myth that every hour of time spent at the hospital means another hour spent in quality medical education. Hiring physician extenders doesn't mean depriving housestaff of the opportunity to see interesting patients and learn necessary procedures. Often just the opposite is the case.

Speaking of naps, many sleepless surgeons have already taken a few - but in the OR, browning out over the field, not at home. Which would Solomont prefer?

Greed vs. Greens, or In Which Righteous Quasitarian Anger is Cooled by Spicy-Hot Chili Sauce on Falafel

I hope you're happy, landlord. You gouged Zen Palate Union Square out of business and you don't have another renter yet.


View Larger Map

A pity that Google Maps' streetview is not festooned with the For Rent banners I saw today on the building at 34 Union Square East. I didn't take a photo, since I was stunned simultaneously with grief, schadenfreude, schaden-anger [Schadenzorn?], and...

...the happy thought that Maoz Vegetarian is just down the block.


View Larger Map

Yummy, and much cheaper than Zen Palate Usq ever was. Maybe I'm not so mad after all.

My talk in Philadelphia today

It's lacking something without the talk, but here's a silent Power Point.

Resident work hours in the Times and the "Journal"

The Well blog at the New York Times talked about the new Institute of Medicine study, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. I'm not likely to read it, but the IOM "asserts that revisions to medical residents' workloads and duty hours are necessary" to protect patients against errors and improve the educational environment.

The comments at the Times blog are to be avoided, as most comments are. Try this New England Journal article instead for a take on the tricky balance between work hours and handoffs. The fewer hours, the more handoffs. And fewer hours, with today's sicker patients, don't mean less work.

"What we do in improving quality can also help us address costs"?

That's what Neera Tanden, a member of Obama's transition team, had to say in this morning's conference call organized by Doctors for Obama, which had over a thousand people listening in.* I wish it were true. 

As I expected, the focus of the call was on outreach and recruitment. Tom Daschle (Obama's pick for HHS Secretary) spent some time talking about the transition team's Change.gov and the umpteen zillion comments that have been offered up there about needed healthcare reform, all of this by way of example of the transparency Obama emphasized during the campaign. "He wants the administration to change the way people interact with their government," said Daschle, "and this is especially true when it comes to healthcare." "We have to have better transparency," he said later - "we can't understand problems until we see them effectively."

The more interesting part of the call was policy, though Daschle averred that no decisions were being made yet: "That's not the role of the transition team, we're working to prepare the president-elect about healthcare options." 

To a question about prevention: "The new paradigm has to be a recognition that prevention has to be a central feature of a new healthcare delivery mechanism. ... But there are serious problems about whether we have the infrastructure to deal with the opportunities that an attention to health and wellness can bring. There need to be more roles for nurse practitioners and physician assistants. We need to make sure we incent people to become general practitioners and family physicians." 

Daschle also talked about improving healthcare delivery ("We have 21st-century operating rooms and 19th-century administrative rooms. The solution to that is electronic medical records and health IT") and quality ("we see an extraordinary lack of best practices and quality of care implemented in procedural ways across the country"). 

To his credit, he did not make the explicit claim (as has been done by others) that improving quality, emphasizing prevention, and implementing efficient delivery of care will reduce health care costs. (I think this claim is difficult to believe.) Nira Tannen made the claim, though: "Making sure our people are healthy will lower long-term costs for everyone and in the meantime ensure that everyone is covered."

To quote Bob Laszewski of the Health Care Policy and Marketplace Blog:

Define quality for me. Then show me a system in which there won't be as many winners as losers--how else do you save 30%? Then I will show you a real health care policy debate and we will see how much consensus we have.

Wellness? Wellness programs today look an awful lot like the voluntary education oriented wellness programs we were selling in 1988 and things are far worse. Prevention? Most of the commonsense steps in prevention were available to us years ago.

We have been avoiding the heavy lifting in health care reform for 16 years. For me, all of these new ideas aren't so much new ideas as one more "Ground Hog day" in the long-running health care debate.

I believe Laszewski over Tannen, though I wish I didn't. The stronger argument for universal care (and perhaps truer to the facts) is to say that covering everyone will cost more money, at the very least in the short term, but (a) it's the right thing to do, because healthcare has become as much a public as a private good; and (b) it's a stimulus to economic growth that people who understand the economy (not me!) say is necessary in times like these.

I should say I was encouraged by the speakers' attention to workforce issues. More primary care physicians, please. But we need more fundamental (re-)thinking about changing healthcare delivery.

*All quotes paraphrased.

an activity of the imagination

set the answer face to face
with its question.
awkward encounter
till the match fails.
who are you to set them up?

"Intoxicado" Does Not Mean "Drunk"

Among Cubans, “intoxicado” is kind of an all encompassing word that means there’s something wrong with you because of something you ate or drank. I ate something and now I have hives or an allergic reaction to the food or I’m nauseous. On the day Willie’s intracerebellar bleed began, he had lunch at a fast food restaurant, the newly opened Wendy’s. His mother and his girlfriend’s mother assumed that the severe headache he experienced that night was related to eating a bad hamburger at Wendy’s - that Willie was “intoxicado.”

More at the Health Affairs Blog about a terrible linguistic misunderstanding. "Neither the ER doctor nor the family requested a professional medical interpreter because each side believed they were communicating adequately."

Presenting the presenters!

I was at Hopkins last week giving a talk as a recipient of one of the GIM Housestaff Research Awards. The other awardees were impressive. I wish they were as blogorrheic as I am, so I could provide links to their life & work. In any case, among the presentations were

• a discussion by Matt DeCamp of intellectual property rights and distributive justice, and their interdependence
  
• Lee Jennings' study of osteoporosis treatment in the hospital (per guidelines: calcium, vitamin D, and anti-resorptive/bone-forming agents). Two percent of patients got recommended treatment in-house!
• a sobering fact about residents' physical examinations of women (Rosette Chakkalakal): they don't listen to the heart like they should (is it because they respect too much their patients' modesty? or they're uncomfortable with moving their breast out of the way?)
• a study by Nitin Kapur of interpartner violence and sexually transmitted infections among Indian women (with a 1-month prevalence of IPV of around 20%, if I remember correctly; related link)

• Last but not least, my study about factors associated with patients' failure to fill new asthma prescriptions [Google version above not yet re-edited to account for Power Point - Google incompatibility].

"Drug-seeking"

Imagine you're in the hospital and in pain. You would like some medicine to treat that pain. Ipso facto presto chango- you are looking for drugs. Hence drug seeking. Voila! A reason not to give pain meds.

The Raucous Baucus Caucus

I skimmed the Baucus policy paper, which is (like the Health Care Policy and Marketplace Blog says) a plan, not a proposal for legislation, with a whole bunch of possibilities that Baucus doesn't really distinguish among. Also, it is a zillion (or 96) pages long. A couple of observations:

Baucus talks a lot about pay for performance plans but never really describes which he prefers, how the current stakeholders will be assuaged, or whether P4P is meant to be the basis for a new payment model - not just a worthy experiment. He also doesn't mention that outcomes improvement via P4P isn't supported by the literature. Then again I didn't expect him to say that. (But maybe he doesn't know that? Senator, a Dr. Berger on the line.)

[edited]

Right on, Max Baucus!

From today's press conference:

We need to train more primary care doctors. I heard only 2 percent of last year's doctors were primary care, because the money wasn't there. We need more medical homes, a more holistic approach to care. There must be a greater role for primary care then there is in America today, and this bill has incentives to do that.

Spelling Hope in Hebrew

From TNR it looks like Yediot Acharonot have chosen to spell Obama with two alefs, and Maariv - with one. Which spelling wins?

The Google, please:
אובאמה
versus
אובמה

I suppose it makes more sense to analyze the word as following normal Israeli Hebrew phonetics, than as a foreign word which needs to be spelled with another alef.

The Emanuels Take Over, 2

Which Emanuel brother are you? (Warning: extreme snark.)

Statins in patients with high C-Reactive Protein "cut the risk of heart disease in half"?

Shorter New England Journal on the JUPITER study
(a corrective to reports like this one)

1. We knew statins helped lower the risk of heart disease anyway.
2. Now we have an industry-funded study to tell us that statins help in people with high CRP.
3. They cut the risk of cardiovascular events from 1.8% (per year) to 0.9%. Yes - a relative risk reduction of 0.5. But 1.8% and 0.9% are both low numbers. Do you have patients who would think this difference meaningful?
4. The study excluded basically everyone we meet in the real world: folks with high cholesterol, diabetes, and kidney disease.
5. We still don't know if CRP risk stratification helps improve outcomes.
6. We're not buying it.

The Catholic worker against torture

Mike Benedetti continues to be idiosyncratically (& admirably) activist - going to DC as part of Witness Against Torture.

Cat and Hat Don't Rhyme in Yiddish: Translating Children's Classics into Mame-Loshn...but for Whom?

Buy our books - and hear about why we translate them - in Philadelphia!

a talk in English by Zackary Sholem Berger, co-publisher at Yiddish House
Thursday, December 4th, 2008, 9:30am
Drexel University
Stern Judaic Studies Seminar Room, Room 302, Hagerty Library
33rd and Market Streets, Philadelphia, PA (map)

All Yiddish House books (including our new Eyn Fish Tsvey Fish) will be available for purchase and signing.

Sponsored by the Judaic Studies Program of Drexel University, Dr. Rakhmiel Peltz, Director.

Breaking News: Obama Cabinet Selection

Secretary of Jewish-American Literature.

The Emanuels Take Over

If Rahm is chief of staff, does that mean we get health care vouchers from his brother?

Public appearances, 1

I got an award, so I'll be giving a talk at General Internal Medicine Grand Rounds at Johns Hopkins on November 14th. Drop by.

Wi Mitzwha for a robber

If you use Google Translate to translate this paragraph of my Yiddish novel-in-progress

וווּ געפֿינט זיך הײַנט דער שׂכל-צענטער?

עס איז וויכטיק צו וויסן, ווי אַזוי דאָס באַוווּסטזײַן ווערט צונויפֿגערעכנט און דעפֿינירט. וווּ געפֿינט זיך דער נאַציאָנאַלער שׂכל פֿון עם־ישׂראל? דאָס איז ניט קיין נאַרישע שאלה. דעת־הקהל, ווייסט יעדער, איז גאָר אַ וויכטיקער פֿאַקטאָר. מע דאַרף פֿאַרשטיין וווּ ער געפֿינט זיך, פּונקט ווי (להבֿדיל) אין די אַלטע שרעקפֿילמען, דאַרף מען זיך דערוויסן דאָס אָרט פֿון צענטראַלן קאָמפּיוטער, דער וואָס קאָנטראָלירט די באַוועגונגען פֿון ריזיקן עלעקטראָנישן מאָנסטער, אויב מע וויל זיך דערפֿון ראַטעווען. פּונקט אויף אַזאַ אופֿן, אויב מע וויל איבעראַנדערשן דעם גורל פֿון אַחינו בני ישׂראל, דאַרף מען געפֿינען וווּ עס געפֿינט זיך יענעם פֿאָלקישן שׂכל־צענטער און אין אים זיכער און גלײַך אַרײַנדרינגען, ווי אַ גזלן לשם מיצווה.

. . . as if it were Hebrew, you get this:

Ouw געפֿינט vessel Heint Ear all - Contar?

Ose Eiz Wichtiq order וויסן, Wi Azwei Dase באוווסטזיין Ouoart Couanoifegarocnt On Eopinirt. וווּ געפֿינט זיך דער נאַציאָנאַלער שׂכל פֿון עם־ישׂראל? Ouw Egofint vessel Ear Nacianalear with all Von - Israel? דאָס איז ניט קיין נאַרישע שאלה. Dase Eiz Nie Kane Earisha question.דעת־הקהל, ווייסט יעדער, איז גאָר אַ וויכטיקער פֿאַקטאָר. Eoat - audience, Waise Eadar, Eiz Gaar a Wichtiqar Pactaar. מע דאַרף פֿאַרשטיין וווּ ער געפֿינט זיך, פּונקט ווי (להבֿדיל) אין די אַלטע שרעקפֿילמען, דאַרף מען זיך דערוויסן דאָס אָרט פֿון צענטראַלן קאָמפּיוטער, דער וואָס קאָנטראָלירט די באַוועגונגען פֿון ריזיקן עלעקטראָנישן מאָנסטער, אויב מע וויל זיך דערפֿון ראַטעווען. Mo דארף פארשטיין Ouw up Egofint vessel, Aponce Wi (distinguish) does not have enough Elto שרעקפילמען, דארף address vessel דערוויסן Dase Art von צענטראלן Campiotar, Ear Wasse Cantrelert enough באוועגונגען von ריזיקן עלעקטראנישן Manstaar, Mo Will enemy vessel דערפון ראטעווען.פּונקט אויף אַזאַ אופֿן, אויב מע וויל איבעראַנדערשן דעם גורל פֿון אַחינו בני ישׂראל, דאַרף מען געפֿינען וווּ עס געפֿינט זיך יענעם פֿאָלקישן שׂכל־צענטער און אין אים זיכער און גלײַך אַרײַנדרינגען, ווי אַ גזלן לשם מיצווה. Aponce אויף Aze way, the enemy of Mo Will איבעראנדערשן דעם von Ahino fate of Israel, דארף address געפינען Ouw Ose Egofint vessel יענעם פאלקישן all - On Contar not אים Azicar On גלייך אריינדרינגען, Wi Mitzwha for a robber.

For the Sausage Factory: Various Health Care Proposals as Fodder for Compromise

Even in the midst of the presidential campaign, we should remember that there are a number of health care plans other than those proposed by McCain or Obama. Given the vagaries of politics, any given plan is very unlikely to be passed. Thus we should become familiar with the details of a variety of them, since any compromise will look like a hybrid.

More in Clinical Correlations.

Needed renovations, or setting the roof on fire?

Our exposure to health care policy - as part of our primary care curriculum - ran the gamut recently.

Last week we went to Washington to advocate for increased support for the primary care workforce. (In brief: we need more primary care health care providers. There aren't going to be enough of them, especially if we start covering the uninsured. We need to create incentives to help people choose to go into primary care rather than the oversubscribed and overpaid subspecialties.) We spoke to young, fresh-faced, intelligent, and hyperinformed health care staffers of some of the Capitol's most influential senators - they were genuinely friendly and happy to see us.

One senator's office is working on a creative idea left over (so they said) from Hillarycare, a "foundation" to ensure a funding stream for primary care education, training, and loan repayment, paid for by a tax on insurance companies. Of course, no one in the room disagreed with that. Everyone realizes that primary care training needs to be dissociated from the current system, private insurance companies and hospitals included. (Our very friendly lobbyist, paid for by NYU Medical Center and along with us to make sure we didn't say anything stupid, was not very excited to hear about this idea.)

This week (thanks to a colleague of mine, whose father is a fundraiser for the senator in question) we went to the office of the junior senator from New York. We spoke to her for fifteen minutes about the necessity to improve funding for the primary care workforce - she was impressively informed, realistic about the political obstacles, and . . . oh, who am I kidding? We were giddy. We got a picture, too!

On Friday, we visited Jack Resnick, an internist (let's say it: a primary care doctor!) with a practice on Roosevelt Island. "[In Washington,] they're talking about payment reform, which is . . . pffphpht! You have to tear out the guts!" By which he means - you have to alter the incentives so as to drastically reduce hospitalization. It's an open secret that hospitals are not the best places for sick people. They breed infections, deconditioning, delirium, psychosis. Resnick's approach (and the approach of this organization) is to closely monitor the chronically ill patients in his practice, keeping the hospitals at bay by providing patients sophisticated but sensitive care at home. It's more feasible for Resnick because (a) he lives on an island; (b) he's ready to devote himself nearly 24-7 to his patients. But this, he says, is the wave of the future - money saving, intensive, personal primary care for the elderly and chronically ill, taking away money from hospitals where it's not usefully spent (or, rather, uselessly overspent).

Resnick, and the AAHCP (see the link above), are behind the Independence at Home Act, a bill introduced in September which would experiment with cash rewards for house-call physicians that trim Medicare outlays for high-cost patients with multiple chronic conditions.

[revised per comments]

Home for the holidays

I was eating a stale Danish in NYU Medical Center's sukkah this morning. On the wall, a notice painstakingly informing the sukkah user that the hut was built by heymishe yidn, the term used by Yiddish-speaking Chasidim to refer to themselves. (The English and Hebrew notices didn't include this fact, by the way.)

But what's this hanging from the ceiling? A red and gold plastic ribbon with a golden bell?

In the heimische sukkah, a heimische Christmas decoration!

Inheriting Radiance

Yiddish poems of home life: my translations of poems by Gella Schweid Fishman and Gitl Schaechter-Viswanath (taken from an upcoming anthology) in Words Without Borders.

Speaking Albanian

To Albany today with my fun-loving primary-care colleagues to advocate for streamlined consent for HIV testing - to make sure all New Yorkers get HIV diagnosis and necessary treatment as early as possible. 

Everyone was nice and I didn't trip over the furniture. 

Enjoy our position paper here. Spread the word!

In Which a Kesher Israel Member Waxes Ecumenical

Psst, Joe! Does Barry Freundel think you and Sarah Palin worship the same God?

reckless beauty
heedless joy
many
people never
panic

clamorous intoxi
cating spaces

living alone
dying embraced

Three and a Half Jewish Philosophers

ZSB: Is there a risk of the religious life?

Hilary Putnam: There’s always the risk of fanaticism. I spend part of every year in Israel at Tel Aviv University. There, the conflicts of certainties are appalling; that’s beginning to be the case in the U.S.

More in the Forward, where I interview Putnam about his new book, Jewish Philosophy as a Guide to Life.

America's Next Top Health Policy Problem

James Knickman, the unassuming and friendly health-policy analyst and CEO of the New York State Health Foundation, talked to our class of third-year primary care residents on Tuesday as part of our health policy course. Here is his list of the Top Ten Health Policy Crises.*

Solutions received by Monday at 7pm will get a free piece of apple-and-honey.

1.The lack of affordable and accessible health care for all Americans.

2. The need to develop methods to decide when to pay for emerging modalities and pharmaceuticals.

3. The need to move resources into prevention and public health.

4. The need to move resources into primary care.

5. How do we care for an aging population?

6. How do we expand physicians' use of evidence-based treatment approaches?

7. Great disparities across ethnic and income groups.

8. Malpractice!

9. Dental care.

10. The lack of health-care professionals.

*Okay, he didn't say "crises," he said "topics." But "crises" is more fun.

"Diagnosis of exclusion"

A zillion years of medical and graduate school, and nearly three years of residency, and I still don't understand what it means when people say that such-and-such is a diagnosis of exclusion. Any diagnosis is a diagnosis of exclusion!

Often, I think, people use that phrase as a retelling of the widespread myth that psychopathologies can't be diagnosed through testing. ("Anxiety is a diagnosis of exclusion.") Or a claim that only laboratory tests or imaging matter, not the history or physical. ("Hepatorenal syndrome is a diagnosis of exclusion.")

The next time someone calls a diagnosis a D of E, by gum, I'm going to ask them just what they mean.

Jewels of Elul CXVIII: A Month of Dreamers that Feels like a Year

with apologies to Craig 'N Co.

Since I have a lot of money, people are always sending me their crazy ideas. And I have to take them home on the train. I fall asleep and dream . . . dream of long vacations, plush terry-cloth robes, little bars of soap you always steal and then feel obscurely guilty about (unless you steal from the minibar, in which case you dream about credit-card bills in the mail and some meaty guy stomping through your front door with a large stick). When I wake up from my dream, I'm at the last station stop and the janitor has to sweep me out of the car with his broom. I wander outside and can't find the bus stop. Scared, I take a taxi.

That's my dream. To some people, it's trivial, stupid, a little cheap. But then I give them some money, and the word "cheap" is never mentioned again. The word "dream" is thrown around a lot, mostly by me. The prophets of Israel, I read, used to dream. Their dreams are full of sprouting sticks, rattling bones with ill-fitting skin heaving themselves reluctantly to their resurrected feet, women eating their newborns. Not Elul stuff at all.

When I think how far I have come, and how much money I have, I thank whatever gods may be for my dreams. I might write them down in a book someday. Dreams do come true!

Well that's all right then

Worried whether your favorite presidential candidate will defeat the other party's lying traitorous scum and save our nation this November? If you care about health policy, don't worry about it. Neither man's plan has a pig's chance at a barbecue of getting anywhere near passage.

Welcome to the hekhsher tzedek community, Orthodox Union!

Or: happy Elul!

So when will the OU withdraw certification entirely from Rubashkin's? When the case goes to court? When a conviction is handed down? When the sentence is served? How many "weeks" will this take? 1? 2? 6? 12? 52?

And why does there need to be a change in management? After all, these are just goyish legal structures we're talking about (ערכאות של גוים). "The law of the land is the law" is just Conservative liberal halachah, right?

Maybe there needs to be another trip to Iowa, company-paid. Make sure one of the rabbis involved "knows some Spanish." Look, the cafeteria is awful clean!

The Art of the Improbable

Today I voted for Paul Newell and Daniel Squadron. Nothing like casting your lot with the losing team! (And speaking of losing...)

* * *

You know what's useful? Reading political news.

Fresh fish for sale!

From there to here
From here to there
New Yiddish fish are everywhere!

Now available:
Eyn Fish Tsvey Fish Royter Fish Bloyer Fish
One Fish Two Fish Red Fish Blue Fish by Dr. Seuss
Yiddish translation by Sholem Berger
978-0-9726939-3-6
$15 + shipping (and tax in NY State)
yiddishcat.com

Don't forget:
Di Kats der Payats, The Cat in the Hat by Dr. Seuss, in Yiddish--$15
George der Naygeriker, Curious George by H. A. Rey, in Yiddish--$18
Colorful alef-beys poster by Stephen Cohen--$12

The futile slow code

I was involved in a slow code recently. (I won't say where, or when, or with whom.) They are slippery and repugnant. Rarely can any of the parties involved say with satisfaction or complete clarity when, or by whom, the slow code was suggested or agreed to. It is a substitute for an honest discussion of options with the patient and family, and it is a legal minefield.

Remind me not to get involved in them again ... when I have a choice in the matter.

The Politics of Kashrut: Kosher Food Boycotts then and now

An event at Town and Village Synagogue. No word yet whether the refreshments will be fleischig.

Join JFREJ, the AJWS-AVODAH Partnership, and Uri L'Tzedek for a salon-style, interactive program: learn about the complex intersections of immigrant rights, labor rights, and Jewish law - from the Lower East Side's kosher meat boycott of 1903 to the AgriProcessors boycott of 2008.

Featuring Professor Hasia Diner, NYU, and Organizers from the United Food and Commercial Workers Union, Uri L'Tzedek, and Hekhsher Tzedek. Presented through Jews for Racial and Economic Justice (JFREJ) and American Jewish World Service and AVODAH: The Jewish Service Corps.

This event is co-sponsored by Hazon, the Workmen's Circle / Arbeter Ring, and Jewish Labor Committee/United Hebrew Trades. For more information or to RSVP click here or call 212-647-8966 ext 10.

Without any negation

We confirm the amazing achievements of Yiddish without any negation at all of the importance of Modern Hebrew, Ladino, Zionism, secular Judaism, Jewish culture as a whole (yiddishkeit) or any other intimate, creative, and authentic Jewish entity and conviction. In addition, we are not all just Yiddishists, of the sort who are committed to Yiddish and only to Yiddish. Just the opposite. We are of various Jewish ideologies. "Whatever we are, we speak Yiddish" - Yiddish is our common property and an integral part of our anchoredness in a part of our identity, our past, and in a part of our future.

--Joshua Fishman, from אַ באַגריסונג־וואָרט לכּבֿוד דעם 100סטן יובֿל פֿון דער טשערנאָוויצער שפּראַך־קאָנפֿערענץ an article in the Yiddish Forward commemorating the 100th anniversary of the Yiddish Language Conference. Translation mine.

Dance of the Dripping-Hand Fairies

I'm no choreographer, but it is important to be meaningful in the movements you adopt in front of the motion-detector paper-towel dispenser. I do want this paper towel! I do! Look, here I am reaching my arms underneath it!

Yiddish is still a national language of Jews

Happy 100th anniversary of the Tshernovits conference!

Studying with Big Pharma

The American Board of Internal Medicine ratifies a core of medical knowledge in which the qualified internist is supposed to demonstrate proficiency. I am using MKSAP to study - it's a series of study guides produced by the American College of Physicians. Before the table of contents, the contributors are listed, together with their disclosed involvement with (meaning: compensation by) pharmaceutical companies.

It'd be asking too much to eliminate pharm-phunded contributors from ostensibly nonpartisan guides which reflect the best available consensus of our profession (that would be...legitimate!). Nor do I think it's likely that their contributions will be vetted by a pharm-free referee (that would be...adequate!). In the absence of these strategies, it would be nice - paradoxically - if those medications mentioned in the text could be listed on first appearance by brand name and manufacturer. Otherwise how are we to know which contributor is putting a golden shine on the clinical evidence?

Day and night

Day and night -
We wait frozen in angry day
for night with its moon,
for moon's tenderness.

We wait terrified in angry night
for day with its sun,
for sun's clemency.

Day and night -
They think we're big,
they make free use of us.

We're small, quite small -
fear pulls us to the ground,
as if we're his, as if he owns us.

So small, what should we
do with ourselves?
Our pain, what should we do
with our pain?
Love?
Secrets?

Day and night -
They think we're big,
they make free use of us.

--Leib Kvitko (Oct. 15, 1890-August 12, 1952)
(my translation; original here)

Poets' homework

Write a poem using only these words.

It should be a good poem.

Work-hour anecdotes battle it out head to head!

Sandeep Jauhar, writing in Slate, has an introduction to the controversy around work-hour regulation for medical residents. 

1. One assumption made by opponents of work-hour regulations is that these regulations are only justified if there is a proven connection between longer work hours and more medical errors. But why is the burden of proof on those who want to change the established order? Why must we assume that the more hours doctors work, the better? Do we know that 120-hour work weeks make better doctors than 80-hour weeks, or do older doctors - who tend to be most vocal in their opposition to work-hour regulations - merely harbor nostalgia for their training days?

Would another helping profession expect its practitioners to work more hours (consecutive or total) as proof of their seriousness? Yes there is overlap between quantity and quality, but anyone who's spent time in a residency knows that an extra hour does not necessarily mean an extra hour of learning or patient care. Sometimes - often - it means an extra hour of drawing blood, doing paperwork, transporting, finding a working EKG machine . . .

2. Jahuar writes:

Work limits have troubling consequences [...] including interruption of
resident learning, fracturing of traditional hospital teams, and the creation of
a kind of shift-work clock-watching mentality among young doctors.

Notice how none of these consequences are referenced to the literature, and in fact each of them could argue, properly understood, for work-hour regulations.

For example, resident learning is "uninterrupted" by fatigue (or lack of concentration) when proper balance between work and other parts of life is ensured.

"Fracturing of traditional hospital teams": I suppose Jahuar is referring here to night-float interns or residents, people who don't work in teams. Or to "orphan" interns, coming in on the weekends when the rest of their team is off, so that someone can be around to admit patients. But how "traditional" is the intern-resident arrangement really? It can't be older (at least in the U.S.) than the teaching hospital, which itself isn't older than a hundred years or so. "Tradition" in medicine changes every few decades anyway - why shouldn't it change now?

"A clock-watching mentality among young doctors" links to a sidebar referencing not a study or review but . . . a conversation the author appears to have had with some young doctors who don't like work-hour regulations. But my colleagues - conscientious, hard-working, caring doctors - like and accept these regulations as a rule. They "watch the clock" only in the sense that every shift worker respects their own commitments whether at work or outside. Martyrdom is not our measure of compassionate, effective care or of professional devotion.

Summer song

Grass under halogen

draped by noonish shadows.

I stroll like a lazy football player

without a ball.

This all happens at summer

when boats cut open oceans.

Hating sweat

I'm waiting for winter.

The Nightfloater's Prayer

Mincha with tallis and tefillin.

A systematic review of the effectiveness of prayer for the sick

[click the post title for the full abstract]
Intercessory prayer for the alleviation of ill health.
Roberts L, Ahmed I, Hall S.
Hertford College, Cattle Street, Oxford, UK, OX1 3BW. leannerobert_uk at yahoo dot co dot uk
Cochrane Systematic Reviews 2007.

BACKGROUND: Prayer is an ancient and widely used intervention for alleviating illness and promoting good health. Whilst the outcomes of trials of prayer cannot be interpreted as 'proof/disproof' of God's response to those praying, there may be an effect of prayer not dependent on divine intervention. This may be quantifiable; which makes this investigation of a widely used health care intervention both possible and important.

OBJECTIVES: To review the effectiveness of intercessory prayer as an additional intervention for those with health problems already receiving standard medical care.

SEARCH STRATEGY: We systematically searched ten databases (June 2005).

SELECTION CRITERIA: We included any randomised trial of personal, focused, committed and organised intercessory prayer with those interceding holding some belief that they are praying to a God. This prayer should be offered on behalf of anyone with health problems.

DATA COLLECTION AND ANALYSIS: We extracted data independently and analysed on an intention to treat basis calculating, for binary data, the fixed effect relative risk (RR), their 95% confidence intervals (CI), and the number needed to treat or harm (NNT or NNH).

MAIN RESULTS: Ten studies are now included (n=7646). We found a slight difference between groups, favouring prayer for death (6 RCTs, N=6782, RR 0.88 CI 0.80 to 0.97, NNT 42 CI 25 to 167, I(2 )83%) but no differences between groups for clinical state, complications or leaving the study early. Individual studies did find some effects. One trial separated death data into 'high' and 'low' risk and found prayer had a positive effect on those at 'high' risk of death (1 RCT, N=445, RR 0.3 CI 0.2 to 0.46, NNT 8 CI 7 to 11). A second study found a positive effect of prayer on women undergoing IVF treatment with significantly more successful implantations in the prayer group compared with standard care (1 RCT, n=169, RR 0.68 CI 0.53 to 0.86, NNT 5 CI 3 to 10). A larger study assessed the effect of awareness of prayer and found those aware of receiving prayer had significantly more post operative complications than those not receiving prayer (1 RCT, n=1198, RR 1.15 CI 1.04 to 1.28, NNH 14 CI 8 to 50) and those uncertain if they were receiving prayer (1 RCT, n=1205, RR 1.12 CI 1.01 to 1.24, NNH 17 CI 9 to 201)

AUTHORS' CONCLUSIONS: It is not sensible to interpret any of the interesting results with great confidence. However, for women hoping for successful IVF treatment there are some data suggesting a favourable outcome of prayer but these data are derived from only one of the smaller trials. On the other hand, one of the larger studies suggests that those undergoing operations may not wish to know of the prayer that is being offered on their behalf. Most data are equivocal. The evidence presented so far is interesting enough to justify further study into the human aspects of the effects of prayer. However it is impossible to prove or disprove in trials any supposed benefit that derives from God's response to prayer.

The piano (a poem by Yonia Fain)

My neighbor, the famous pianist,
has gotten ever sicker the past two years,
his body has slowly shrunk
as if he were hiding himself from the world
and somewhere, with trembling hands,
holding onto a concealed
center of life.

And then one day
he entrusted me
with his apartment keys.
He had to go into the hospital
for an operation
and he asked me
to take care of his two vases
in the window.

"I can bring them to my place,"
I offered.

"No, no," he stammered.
"The piano has to live with somebody."
He hung his head
and added as if embarrassed,
"If you have time, it would be good
if once a week, in the evening,
you could just sit for a moment
by the piano."

(from Der Finfter Zman, CYCO Farlag, 2008. Original Yiddish here. Translation mine.)

Kay Ryan, poet laureate

In honor of the poet laureate being someone whose books I actually own, a selection. A short selection - the shortest possible. One poem.

Great Thoughts

Great thoughts
do not nourish
small thoughts
as parents do children.

Like the eucalyptus,
they make the soil
beneath them barren.

Standing in a
grove of them
is hideous.

(from Say Uncle, Grove Press, 2000)

More health care is not better

What explains the large variation in health care costs across the country? You would expect that the regions with the highest health care expenditures have the sickest patients, or have the highest prevalence of chronic health conditions.

But you would be wrong. Health care expenditures are highest where health care supply is the highest. As the number of hospital beds, doctors, and medical technologies (”supply-limited health care”) increases, the use of these goods increases as well.

More in Clinical Correlations, the blog of NYU Internal Medicine.

Why People Become Cannibals

There's cameraderie.

There's shared values.

They practice what they preach.

And there's always someone to have for Shabbos lunch.

[thanks to House of Gil for laying out the principles]

Best medical quote ever

“It’s incumbent on the community to dispense with the need for evidence-based medicine,” [some cardiologist] said [in the New York Times, in support of expensive, unproven "CT angiograms"].

Couples Therapy

I never lend a hand
when I can take yours
to drag our couple
across unders and overs.

What brought us together
is chicken-or-egg.
You bring and I give.
We cry and we beg.

My hobby

(with apologies to xkcd)

Judging articles in the medical literature based on whether the authors have cool names.

Boring paper:

Project LIFE-Learning to Improve Fitness and Function in Elders: Methods, design, and baseline characteristics of randomized trial.

Morey MC, Peterson MJ, Pieper CF, Sloane R, Crowley GM, Cowper P, McConnell E, Bosworth H, Ekelund C, Pearson M, Howard T.

Good paper:

Enck P, Zimmermann K, Menke G, Müller-Lissner S, Martens U, Klosterhalfen S.

A mixture of Escherichia coli (DSM 17252) and Enterococcus faecalis (DSM 16440) for treatment of the irritable bowel syndrome - A randomized controlled trial with primary care physicians.

Excellent paper:

Adeoye AO, Omotoye OJ.

Eye disease in Wesley Guild Hospital, Ilesa, Nigeria.

Afr J Med Med Sci. 2007 Dec;36(4):377-80.

Note that the Dutch are usually at the top of the heap as well. How can anyone resist these authors?

Thyroid hormone transport and metabolism by OATP1C1 and consequences of genetic variation.
van der Deure WM, Hansen PS, Peeters RP, Kyvik KO, Friesema EC, Hegedus L, Visser TJ.

Passion with a purpose

I don't read a book
One moment after it stops exciting my
Curiosity or interest, and this passion
Has finally stopped my reading altogether [...]

-David Shapiro, Poems from Deal, 1969
(thanks to AS)

Today's Strand haul

This is a blogpost, so motivated by a blend of two complementary impulses: preening (look at the books I'm reading! aren't I erudite!) and the search for people to share the books with (talk to me about them! what do you think?).

I did get some nice stuff today, and I hope the upshot here will tend more towards the second motivation than the first:

גימטריקון (Gimatrikon), i.e. a gematria dictionary
Rats, Lice, and History
How We Die
The Poems of Gerard Manley Hopkins
The Courtier and the Heretic: Leibniz, Spinoza, and the Fate of God in the Modern World
The Examined Life: Philosophical Meditations

Growth Song

Children are drinking from lukewarm brass gargoyles.
The wheel gruntingly swivels.
I stand in the field directing sprouts
mediating growth from sand to sun.
Let me be a mother-man.

Simply not honored? The "hypersensitivities" of Jewish women

Often the most interesting part of a responsum, especially a traditional responsum redolent with the assumptions of strict construction (one merely has to read the law correctly out of the proper book, and all will be truth), is not so much what is termed the "halachic analysis" (quoting sources, lists of poskim) but the interstices of the argument, in which the strict-construction myth is exploded despite itself: opinions do matter in the interpretation and creation of halachah, and in many a halachic analysis the posek's personal notions are determinative.

Consider the newly posted review (at the Seforim blog) by Rabbi Aryeh Frimer of Rabbi Daniel Sperber's Darka shel Halakha. The majority of his explicit argument is (a) Sperber misunderstands the original Talmudic statement about women and aliyot; (b) Sperber misconstrues the scope of kavod-haberiyot - it can only temporarily nullify a rabbinic decree; and (c) Sperber misapplies kavod-haberiyot to the matter of women reading Torah.

Two side comments, however, throw as much light on Frimer's argument as do the more bibliographic portions:

[I]n the case of aliyyot, no act of shame has been performed to all
those not called to the Torah (both men and women); they are simply not honored.

This is incorrect. As R. Frimer surely knows, reading from the Torah at fixed times is one of the basic requirements which a Jewish community must fulfill (not, as far as I am aware, an individual requirement, as he seems to assume). In the case of a man, not being called for an aliyah at one occasion means "simply" that he must wait for another occasion. But the possibility remains that he may someday be called. For an Orthodox woman, she will never be honored. Thus "both men and women" is a misleading formulation, and "simply not honored" is rhetorical sleight-of-hand: if one can never be honored - never participate in a basic community ritual - I think shame is something to be careful of.

The second group of misstatements is more revealing.

This view [of many rabbis] explicitly rejects subjective standards - in which what is embarrassing results from the idiosyncrasies or hypersensitivities of an individual or small group. The vast majority of religiously committed women are not offended when they do not receive an aliyya. Indeed, they understand and accept the halakhic given, although some might clearly have preferred it to be otherwise.

"Idiosyncrasies" and "hypersensitivities" are strange terms to be applied to the spiritual strivings of half of all Jews - to which Frimer begins his essay with an avowal of respect.

And then - how does R. Frimer know that "the vast majority of religiously committed women are not offended when they do not receive an aliyya"? Has he talked to them? Or are "religiously committed women" defined as those who do not think about receiving aliyot? In any case, the formulation "...when they do not receive an aliyya" is again misleading, implying as it does that we are considering an individual aliyah, one of many, which Leah or Sarah happens not to be called for at a particular moment. Rather, as I pointed out, we are talking here about the wholesale exclusion of a very large group (half of all Jews!) from a basic community obligation.

Finally:

More importantly, does it make halakhic sense that if a group of women – nay, any group, says: “this Rabbinic halakha offends me” – be it mehitsa, tsni’ut, kashrut, stam yeynam, many aspects of taharat ha-mishpahah, who counts for a minyan, and who can serve as a hazzan - then we should have a carte blanche to go about abrogating it. Such a position is untenable, if not unthinkable.

More rhetorical sleight-of-hand! The premise in this paragraph is not being advocated by any party to this dispute (or indeed any observant Jewish feminist!). I very much doubt that R. Sperber is indicating that any group which thinks itself offended by a given Rabbinic edict "should have a carte blanche to go about abrogating it" (whatever that means). It is true that when a Rabbinic edict does lead to the wholesale exclusion of women, the circumstances of the legislation (whether or not they apply, and when) should be very carefully examined. No slippery slope here, merely R. Sperber's derekh-haTorah.

To reframe the question R. Frimer is asking (but without the stacked deck): does it make halachic sense that a community which values the spiritual striving of women should consider whether its own honor is sensitive to their wholesale exclusion? The question answers itself.

Should we specialize medical education?

It's common wisdom that surgeries are better done at high-volume centers. Specialists should do what they're best at - this reduces errors.

By analogy, medical schools should do what they're best at. Different medical schools are (I speculate) better at educating different types of doctors: NYU might be better at training primary care physicians, while Columbia (to pluck a name out of the air) might be better at training future cardiologists.

So why can't medical schools specialize? Why not telescope the long and tiresome haul of medical school-residency-fellowship into a single training program?

We know "physician" is a variegated profession. Why must all doctors be trained the same? Wouldn't it make sense for a medical school to be able to choose an area of specialty, rather than trying (fruitlessly) to be all things to all possible future doctors?

The Yiddish Leprechaun of Baltimore

Presenting the genial, silver-tongued, exaggeration-prone professor (and friend of mine), Marc Caplan. His life story is worth reading about.

(He was a guest on this very blog some time ago.)

Chasidim complain about Maimonides?

Last week's issue of Zeitshrift, a Yiddish magazine from Monsey, has this cover headline in red and black:

The Truth About Maimonides Medical Center
Community leaders and dozens of former patients complain to Zeitshrift about negative treatment in the Borough Park hospital - Some leaders say that other hospitals aren't any better - What can we do to improve the situation?

Inside is a 15 (!)-page article about the hospital, its detractors, and its defenders.

GG is for pluggable

Are you looking for kids' books which are witty but not saccharine? Look no further than AA is for Aardvark, the latest creation from the unjustly unfamous Mark Shulman (a friend of mine), brimming (both author and book) with wordplay, illustrations, and double letters.

Saving a life - according to the doctors. II

If a non-rabbi could decide what sofek pikuach nefesh means, could a doctor do it? I'm not sure, because I don't think the work of a doctor has much to do with calculating mortalities - that is more fittingly the work of an actuary or an epidemiologist. If you ask a doctor, given a certain presentation of symptoms, what is the chance that a certain patient sitting (or lying) in front of them will die, they will generally say, "It depends on the patient." Doctors are notoriously reluctant to give probabilities.

Even if doctors are reluctant to quote such possibilities, maybe they still practice according to them? The literature on medical decision-making gets broader every day, and I fear to tread where I am ignorant. I know enough though to say that it strongly depends on the specialty. Sometimes subspecialties of medicine differ so much from each other it's as if they are different professions altogether. The emergency-room doctor and the critical-care physician deal in life and death every day, while the outpatient practitioner has influence in the gradual development of healing or disease - these are broad generalizations, of course.

Not blinded in Belarus

When this study on breastfeeding and IQ was hyped in the press (MSNBC; see WebMD for a better take) why did no one mention that the pediatricians who rated the IQ of the children in question (more vs. less breastfeeding) were not blinded to which group the children were in?

I would understand if the findings of the study were a slam dunk, but they aren't: verbal IQ was the only category with a statistically significant difference (performance and total were not statistically significant), and the IQ difference is probably not behaviorally significant in any case (what's five or seven points?).

Given that the differences are small and possibly not statistically significant, it behooves those reporting the news to give a sense of potential sources of bias: factors which could skew the results in one way or another. And one way in which results can be skewed is for raters to "know" or "guess" while rating the children in one group that their IQ should be higher. We are all inherently biased creatures - blinding is the way, in modern epidemiology, to reduce bias. When small results are claimed (as they are here) a source of bias like this is quite worrisome.

The cognitive benefits of breastfeeding remain unproven.

(Of course my son is being breastfed - with formula too. But the reason he'll grow up smart, God willing, is because his mother is smart.)

Grass-roots beef

Not surprising: the organizational impetus and scholarship behind the growing concern with Rubashkin's - this comes from the Conservative movement's rabbis. But the grass-roots activism comes from the Orthodox (albeit the most liberal).

A bright-eyed fish (or: how do you write "ghoti" in Yiddish?)

I had the pleasure just now of holding in my hot little hand a sample copy of Eyn Fish Tsvey Fish Royter Fish Bloyer Fish, our new Yiddish translation of Dr. Seuss's ichthian classic. It looks yellow and lovely and typo free. (Jinx!) More details when the whole shipment wends its way to us from Singapore. Save up your pennies!

(The cat and the monkey you already have, yes?)

PTSD in the military

The findings suggest that psychiatric disorders in Marines are diagnosed most frequently during the initial months of recruit training rather than after combat deployment. The disproportionate loss of psychologically unfit personnel early in training creates a "healthy warrior effect," because only those persons who have proven their resilience during training remain eligible for combat.

Saving a life - according to the doctors

A conversation in the bikur cholim room:

"Doctor, if a man had chest pain, can he walk home for two hours [on Shabbos]?"

"It depends what kind of pain."

"The doctors said it wasn't heart pain. Can he walk home? I don't think it's safe to walk home. The rabbi said he could take a car home."

From this conversation (which went on for some time) I learned a number of things. One of them was that the guy in question (who got to ride back to Borough Park on late Friday night via car service - I wonder if he got dropped off a couple of blocks from home?) has 11 kids in his house. No wonder he's having chest pain.

The other was that the Satmar rebbe (the recently deceased one? one or more of his quarreling heirs?) apparently was of the opinion that presenting to the hospital with chest pain was enough of a sofek pikuach nefesh to make riding in a car on the Shabbat permissible.

This raises all sorts of questions, predominant among which (as usual) is whether this opinion as relayed to me by Some Random Satmar Guy is faithfully rendered at all. Maybe the Satmar rebbe (or various present-day quarreling rebbes) holds nothing of the sort. If that's the case, never mind.

However, let's assume that the above rendering is true. Then two questions: (a) is a doctor the right person to ask for the definition of sofek pikuach nefesh? (b) if a doctor is the right person to ask, how would she judge?

A doctor might not be the right person to ask because one might hold (I don't, but one might) that halachic categories are to be determined by halachic authorities. Just as pikuach nefesh has a halachic cutoff (several, actually, but "a dangerously ill person" being the most prominent among them), so does sofek pikuach nefesh. The problem is that while there are intricate discussions about the precise definition and interpretation of safek sfeika, the issue of sofek itself is something I'm not aware of any conclusive opinions about. Is doubt probabilistic, intuitive, psychological?Thus even the strict constructionists - which I am not - who believe in immutable and exactly specified halachic categories would have great difficulty specifying a sofek pikuach nefesh, let alone a pikuach nefesh, without the help of health workers.  

The question is, how are we to translate halachic categories into medical ones? There are sick people who look terribly ill to the layperson but a doctor knows (or is said to know!) that these people will get better. The converse is true. 

Then it is not rabbis alone to whom we need to have recourse in the definition of sofek pikuach nefesh (as I write this I more and more realize that pikuach nefesh itself has the same definitional complexities), but health care professionals (most often doctors) together with rabbis. 

I don't think doctors can make the definitions; that's for halachah to work out with their help. But doctors do need to figure out some way to translate their thoughts into lay-cum-halachic language. And that is difficult, for epistemologic, not just lexical reasons.

In the next post I consider how a doctor might answer the question, "Will I die with this chest pain, doctor?" In the interim, though, consider the possibility that the doctor is not the right person after all, but the community. 

An example of this position is found in an interesting article by a Rabbi M. M. Farbshtein (I don't know if I'm transliterating his name correctly) in the journal Assia (my translation):

[T]he question up to what level of possibility [doubt, sofek] something is considered sofek pikuach nefesh does not have an objective answer, but rather [is according to] the assessment of the community that the activity was done for the sake of saving a life [pikuach nefesh]. The situation in which such an activity is required is considered to be "sofek pikuach nefesh."

The question then becomes: what community are we talking about, and how does it decide?

That's too big for now. We'll return to the doctors in the next post. What does "risk of death" mean for a doctor contemplating a patient with chest pain?

Phrases I could say all day

Seronegative spondylarthropathies!

A letter to Sholom Rubashkin

Read the letter here. ("Effective June 15, 2008 we will stop patronizing any restaurant which serves your meat.")

Patient docility

Some call it patient compliance; the more current term is patient adherence. Retro is cool now, though. (I know a guy who wants to call Yiddish zhargon again [translation of headline: "Say it in Zhargon!".)

So we might as well follow the retro trend and call it patient obedience. Just like they should have termed it with all honesty in the good old days.

I love American Spanish!

The picture is from a bathroom in the Bellevue adult outpatient medicine clinics. I also know the phrases apretar el botón or tirar [de] la cadena - but I like floshar much better.

In our Yiddish at home we say aroplozn dos vaser; I know people have also said (op)shvenkn dem klozet. Of course, just like American Spanish, in American Yiddish nowadays 99% of people say (I bet) floshn. I use that word too, with guilty pleasure.

What do you know and when do you know it?

Doctors and patients think differently. One way to understand this difference is to ask the question: how do doctors and patients know? If we try to understand our own ways of knowledge (epistemology), how our patients might know, and how the two differ, this might be productive for our practice of medicine and our patients' health.

See my poster on the topic. When you're done looking, check out the thought-provoking companion exercises. Lastly, make yourself a cup of tea (Lapsang Souchong), sit down, take a minute, and write down your epistemology on a piece of paper. Please e-mail that epistemology to me; I'd like to start a database of such statements-of-epistemology. So far I have an N
of ... 1.

Bris reprise

Summary, pix.

Cheshbon, please!

I'm sorry we had to read another Forward article with the headline "Venerable Journal In Language We Don't Read Closes Its Gaping Mouth" - and I do agree with some of the basic facts: less readers of Yiddish, less writers of Yiddish, blah blah blah zzzzz. (Fewer Yiddish letters, even. Now there are only 16: we had to lay off everything after samech. Sad.) But pleeze, if you do have a Yiddish journal, or care about Yiddish writing (yours or anyone else's), don't expect my pity until you do your utmost to share the wealth of the words you care for. Make sure your journal gets to those who want to read it (I didn't even know the journal still existed - too late now, I guess)! Make sure, for goodness' sake, that your journal has a Web page! As Miriam Koral points out: make sure that you are training your successors! Don't blame the younger generation (thanks for the sneering assessment of your juniors in the last sentence of the article, Mr. Departing Redaktor!) until you get to know them.

EBMBS

What is the effectiveness of pediatric CPR?
What is the effectiveness of laypersons' pediatric CPR?
What is the effectiveness of classes for laypeople about pediatric CPR?
What is the effectiveness of e-mails advertising classes for laypeople about pediatric CPR?

A bris!

Details on request.

Pesach cleaning: universal and particular

I love driving out the leaven. But when I talk to the third or fourth Spanish-speaking immigrant patient who couldn't visit her doctor (me) for weeks before Pesach -- she works for a Jewish family, who "can't give her much time off"-- then the phrase fiestas judias begins to sound a little funny.

* *

I wanted to go memorialize the Warsaw Ghetto uprising, but it's too close to Pesach. I suppose this should make the historical memory even sharper: in varshever geto iz itst khoydesh nisn ("in the Warsaw Ghetto it's Nisan now" -- Binem Heller).

Too bad!

I'm sorry Abbott Katz (great name! - is it for real?) has a problem with "ultra-Orthodox". (I prefer "benighted Yiddish-speakers," myself. Or "Cholentists.")

I have a problem with "Orthodox." Not with the term itself but its use. Whenever someone is observant, or considers themselves bound by halachah, the term "Orthodox" is always put into play in the article describing them. This seems to happen most often in the Times.

I do accept the term when my work friends or colleagues use it to describe me, because they're not looking for a lecture on twentieth-century Jewish religious or intellectual history. But I'd rather be called Conservative, or frum-egal, or sho(y)mer mitsvo(s/t), or (halachically) observant/pious/devout/hyper-religious, or (failing all else) "that guy with the yarmulke/kippah/lid/skullcap/hat."

Bits of work, or: Passover primary-care cleaning

Yesterday I taught a class to (better: had a discussion with) my colleagues in the Primary Care program about risk perception.

Today I gave a presentation about some ongoing research: (to what extent) do patients and the medical chart differently report the doctors' reason for their hospital admission?

You can attend the talk too!

The dove wobbles slowly on

Ode to the Dove - a puttering translation continues.

Sutzkevers

I'm over-ideological, I know, but I wonder what language Rina Sutzkever and her father speak to each other. Hebrew, I would guess?

So many notes!

Feast your ears on this collection of Pesach tunes.

Gee, thanks, I guess

Patrick Radden Keefe in Slate on Fujianese immigration:

With their scattered diaspora and entrepreneurial traditions, the Chinese have sometimes been called the Jews of Asia. The Fujianese, who are famous for their adventurism and business savvy, are occasionally described as the Jews of China. The people of Changle, Lin Li tells me, are the Jews of Fujian Province.

"Entrepreneurial traditions"! "Business savvy"! How polite of you, Patrick.

Disgusting!

The first word my blonde daughter sought out
was Disgusting.

We slop around the pure dough with washed hands
pebbled with healed scars.
Mushing it around. It slops
over the edges,
this loving mix
shaping prevarications.

Touching the new loaf
brings my head into alignment at last
all the more so with butter ready
and a clean knife.

From permanent hesitation to mature skepticism: growing doctors

During today's lecture on decision analysis:

Most of our interventions don't help patients. And isn't that a bitch.

The Thirty-six Million Dollar Rectal Exam

In 2004, while working at a construction site, Brian Persaud was hit in the head by a large wooden plank, lost consciousness, and was taken to the emergency room at New York Presbyterian Hospital. There he received what he says was an unjustified digital rectal exam. Persaud brought suit against the hospital, and soon, four years later, the case will come to trial in the New York State Supreme Court. The arguments in the case are legal, but the underlying issues are also medical and ethical.

More at Clinical Correlations, the NYU Internal Medicine blog. (Thanks to D.M. Esq. for a quick legal education.)

Titsher!

Katle Kanye brings shalekh-mones (Purim gifts) to a neighborhood English teacher (a titsher is an instructor for secular subjects among Yiddish-speaking Chasidim). Translation mine.

We rang the doorbell and the door was opened by a Jew of about sixty, short, with a pointy beard, in a white shirt without a tallit katan, and with a black yarmulke - but made of cloth. In other words a yekke-ish Jew. I mean, we're talking about titshers and except for a convert or a newly religious person it's really rare to see a Chasidic titsher. My nephew, as a matter of fact, has a Chasidic titsher, born and bred into holiness, who teaches the kids English - in Yiddish. If they can teach Hebrew in Yiddish, why not English? As to what they call him: Titsher Felberblum. Since he's a rebbe in the mornings what to call him is a momentous question. If they called him Rebbe Felberblum that would mean that a rebbe is teaching English to the children, something which shouldn't be seen or found. If they call him Mister Felberblum that would mean they're calling a melamed Mister - but then the people would cry out at this dishonor they stabbed our Rabbi, they knocked down our Rabbi! So then what did they do? Just calling him titsher would be fine for goyim or goyish Jews. But you can't refer to as titsher a Chasid with a gartel and shoes and long socks, someone who calls his fellow an evil name has no part in the World to Come. A compromise was hit upon: Titsher Felberblum. This incorporates both his Jewish name and his profession of secular studies. Thus the Torah doesn't God forbid come to be shamed, and the morning melamed's glory remains in its place.

ברוך מחיה מתים / Resurrection

Fafblog is back.

The only skill that matters in treating a patient?

The ubiquity of UpToDate is not without its troubling features (although, to be fair, most UpToDate articles include more references to evidence-based medicine than old-school textbooks - or old-school colleagues - ever entertain). So Darshak Sanghavi's article in Slate serves a useful purpose.

But he really didn't mean to write this, did he?

However, the sheer abundance [of knowledge taught in medical school] crowds out an important—in fact, the only—skill that matters in treating a patient: how to critically appraise published clinical trials.

The only skill that matters? How about:

1. talking to the patient (not trivial!)
2. eliciting the patient's wishes and preferences
3. diagnosis (including the use of diagnostic tests)
4. elucidating the treatment options and formulating a question
5. judging what the best evidence is for the particular clinical question
6. applying the best evidence to the clinical question
7. discussing treatment options with the patient
8. ensuring patient compliance/adherence/agreement/cooperation/investment

Pediatrics (the author's specialty) can't be that different!

Who pays standup tragedians?

Standing on a streetcorner
making children sad.

The shade splinters sun
and my daughter from another room
spears me with a laugh.

I'm climbing the walls of guilt.
I feel the echoes
of your coming fury.

Every dying plant is reinherbated
growing sans boundaries:
just dirt.

One age, one stratum of stretching for light.
Of farting noises, ice cream cones
and springing eagerness for chocolate.

Happy Purim!

Who has time to get drunk on Purim? I rarely manage to have more than a shot or two. How is Blanca ever going to learn to say "Father, dear father, come home with me now/The clock in the steeple strikes one"?

Some doggerel, if you're not getting shalekhmones from me.

If you're a rabbi, judicate
If you're a doctor, cure
If you're a heretic, be in doubt --
if scalpling, be sure.

If you're a cookie, delectate
if Esther now, don't fast
Don't gird yourself for battle
The lots are long since cast.

If sworn enemy, think it over
If you're our God, defend
This year, Esther, let your hair down
like a child, pretend.

My minyan is a bunch of suckers

I don't show up for six months, and instead of berating me they let me lead davening. As the poet Nauen pointed out, it's because I don't show up every day. If I did, then familiarity etcetera.

Nice to form a part again of the jaunty ricketiness - my missed words here and there, my shaky transitions into and out of a near-perfect Torah reading (someone else read, hence the near perfection).

I always feel like Tachanun shouldn't be said during Adar either; someone always has to remind me.

Medicosocial misfits

I wish David Brooks' column on people with rank-link imbalances (i.e. those with "all of the social skills required to improve their social rank, but none of the social skills that lead to genuine bonding") didn't seem to apply so strongly to a number of people I know in medicine. Unfortunately, success in the profession of medicine requires social rank - but success in the craft of medicine (patient care!) requires genuine bonding.

Cernăuţi/Чернівці/Czerniowce/Czernowitz/Tschernowitz/טשערנעוויץ

Yiddishists: fighting against inferiority since 1908.

Ode to the Dove

I am still translating it - verrry slowly. Help me out.

Competent to judge: Adventures in hospital ethics

The guy with newly discovered metastatic cancer who was just told of his diagnosis - when he wanted to up and leave, that wasn't crazy of him. Nor was it necessary to call a psychiatrist to judge whether the patient was competent to leave against medical advice. Is there anything magic about psychiatrists which makes them able to judge competence? Some people like titles, and other people like subspecialties. Psychiatrists on call in the hospital become surrogate ethicists, for a reason I don't understand. Because psychiatrists are on call and ethicists are not? Or because we (doctors and everybody else) tend to confuse the legal with the ethical - and we're familiar with psychiatric judgments of mental illness?

It would be too easy - unfair, really - to say that some doctors who think patients are incompetent, or crazy, are unable to see why anyone might disagree with them. But I'll say it anyway.