12/28/09

More mourning for Yiddish

I don't want anyone to lose their job teaching Yiddish at the University of Maryland, certainly not Miriam Isaacs, but it would increase sympathy if people quoted in newspaper articles would be careful not to say things like this:
"U- Maryland has had the biggest commitment to Yiddish as a language anywhere in a hundred-mile radius," says Harvey Spiro, president of Yiddish of Greater Washington, which organized a letter-writing campaign. "We're not a particularly political organization, but this kicked us in the gut."
Umm...I think Johns Hopkins is near the University of Maryland, no? And they have a great Yiddish teacher.

12/24/09

Authenticity as aesthetic (or: what is coherence and integrity?)

In the Forward, Jay Michaelson says that "the myth of authenticity has got to go." In the liberal circles that he and I travel in, this claim isn't all that surprising or challenging. I believe he's mostly talking to those of us whose subconscious, when asked to provide the image of an archetypal Jew, summons up a fundamentalist of our time or a prehistorical figure - anything but one of our own hyphenated, conflicted kind. But the hyphenations and conflicts, say Michaelson, are part and parcel - perhaps even the most admirable element - of Judaism. Most of what we value is transient, and always in flux.

What should we pursuing if not this myth? Michaelson gives several rephrasings of what I presume is meant to be the same idea: whatever religious, literary, or cultural form "speaks to the depths of what it is to be human," "get[s] to what matters" or is "resonant." Finally, though, he comes down to the core of his alternative definition: "a personalized notion of authenticity measured by integrity and individual coherence." I don't know what that means, but let's say for the sake of argument I pretend to. I can think of two problems with this.

First, coherence is a cousin of consistency, the hobgoblin everyone loves to hate. There's a reason for that: we all know complete bastards who are thoroughgoing and consistent in their personal behavior. What resonates with them, unfortunately, is nothing the rest of us would touch with a 10-foot pole. I suppose this is why "integrity" makes an appearance, but that's a slippery fish itself, and Michaelson owes us a more rigorous definition.

The second problem is that Judaism, for all its flux and change, is not predominantly a collection of individual non-interactors, each (with integrity and individual coherence, naturally) pursuing their own direction: a Brownian-motion people. Things get popular and define, in large measure, the majority of the Jewish community. So American Jews like "bagels and not jahnoon" because there are more Ashkenazic Jews than other varieties. Similarly, "Joseph Caro’s legalistic Shulchan Aruch" beat out his radical, mystical “Maggid Mesharim” because the former became popular and frequently referred to while not the latter. It's not complicated: people seek community. As sociologists (most notably Arnold Eisen) have pointed out, the majority of American Jews light Chanukah candles and make some sort of Passover Seder even if they don't know or care about the halachic or historical underpinnings of the holiday.

The problem, in short, is that whatever Michaelson's aesthetic (for that's what it is - and I mean that as a believer in the importance of aesthetics), there will still be practices and assumptions regarding Judaism which the majority of a certain community of Jews adopt. Unless "internal Jews" like him find a way to convince the rest of us what exactly he means by that coherence and integrity, we will be left out of his aesthetic. I don't know whether that would be more to his or our detriment.

12/16/09

ABBA in Borough Park

Social scientists rethink the relationship between Chasidim and modernity.

Sometime in 2001, if you were a Chasidic woman in Borough Park, you would have noticed a teacher's assistant who looked out of place at your daughter's school. You would have been familiar with non-Jews and non-religious Jews from their stores and magazines. But you would never have expected someone not quite right to be in your daughter's classroom. She was nice enough, an intelligent woman with a shearling coat who spoke a good Yiddish. But it was clear what she was not: a haymishe fro, a Chasidic woman. You went to the principal to voice your concerns. Could it be that outside influences had invaded your daughter's school so easily?

The woman was politely asked to work somewhere else, and she did. Once in a while you saw her in the community, though never again at that school. But who was she?

You heard from your friends that she was a Jew from a non-religious home, studying in a university to be some kind of professor. She was Ayala Fader, an anthropologist - and her subject was not an obscure group of hunters near the Amazon, but the Chasidim, and how Chasidic girls are raised to a particular kind of devotion.

* * *

Perhaps you have thought of Chasidim as a pre-modern, separatist sect, with their own strange costumes, quaint language, and deliberately different, even contrarian customs. But - according to a nascent body of work by researchers interested in contemporary Chasidim - you would be wrong. It is not how Chasidim avoid modernity which enables them to survive as a self-defined group, but how they negotiate with, cleverly re-interpret, and, in the final analysis, appropriate modernity as their own.

Fader (an associate professor of anthropology at Fordham University and author of the new book "
Mitzvah Girls: Bringing Up the Next Generation of Hasidic Jews in Brooklyn" (2009: Princeton University Press) asks the same question about the Chasidim that you would: how can they participate only piecemeal in the surrounding world? Not, Fader says, because they are ignorant of its attractions or advantages, but out of religious and philosophical reasons: "they use the sense of their own authenticity, including a nostalgia for a lost, purer past in Eastern Europe, to make this historical moment just one more point in a redemptive narrative." Our superficially new modernity is just a repackaging of the same old Exile.

Many of the details of Fader's research have to do with raising Chasidic children, the "mitzvah girls" of her title. What is the special religious instruction tailored to Chasidic 5-year-olds? There is none: "these 'choices' [of daily life for children] are socialized in [Chasidic] kids through everyday interactions, not religious training." Fader spent hours and hours with her tape recorder, observing just what social interactions make up the Chasidic child: no, you can't draw a purple apple because apples aren't purple - even if the imagination would like to suggest it; no, you can't ask what the Mishnah is because girls don't learn about the Mishnah - even if you might be curious about it. When the proper choices are socialized by thousands of interactions with parents and teachers, they become second nature.

But conscious choices even in an area as rooted in the unconscious as language, also play a role in the self-definition of Chasidim. Sarah Benor, a sociolinguist at Hebrew Union College in Los Angeles, has written about the strategies used by Jews of different varieties to construct their version of Jewishness. Much as the Jewish English of American liberal Jews is not a distinct language, or dialect, but rather a repertoire of words and phrases consciously chosen for effect, Chasidic Jews flit between Englished Yiddish and Yiddished English to display their status to the outside world and mark their own status within their world.

Social interactions and language - somewhere on the border of conscious and unconscious activity - are important to the self-definition of Chasidim. But what about those elements of culture which people choose because they relieve the monotony? In other words: what about fun?


Asya Vaisman, a research fellow in Jewish studies at the University of Washington, recently defended her doctoral thesis at Harvard on the Yiddish songs and singing of Chasidic women. She tells a story from her research which shows that music, like language, helps define Chasidic separateness despite its porousness: "A Belz woman in London told me that her daughter was 'naughty' once and used songs by ABBA for the melodies in one Hasidic production." The headmistress had never heard ABBA, so she approved the songs. On its surface, the lesson of the story is clear: non-Chasidic culture (like ABBA) can only be allowed in if its provenance is hidden or denied. But the point might be even more subtle: as long as the maxims of cultural restriction are obeyed, the odd outside influence can slip through (and productively used) without undermining the foundations.

Today's researchers into Chasidic culture might thus be coming to a new consensus. Perhaps ten or twenty years ago, Chasidim were seen as a defiantly separatist sect, whose entire raison d'etre is a thoroughgoing opposition to modernity. Now Chasidim are seen (as Fader puts it) as creators of another, parallel modernity which communicates with our own. Only through understanding these dual modernities can we appreciate the importance of the niggun that comes from a secular Yiddish poem; the hairstyle which is "shtoddy" (fashionable) but not too much; the shifting from "Toyre" (with a Yiddish accent) to "Torah" and back again in order to "pass" as more or less modern.

Do Chasidim themselves see modernity as negotiable? R., a Yiddish journalist with a day job in finance, said via e-mail, "There are good and bad sides to modernity like anything else. I think a Chasid can extract the good elements from modernity: (relative) openness to other schools of thought and a readiness to change one's worldview, in the framework of traditional observance."

Katle Kanye is a Chasidic blogger. In contrast to R., he is skeptical about the modernity of Chasidim. "Modernity is fine. It keeps the house warm, you can use it to fly to see the rebbe a few times a year, view a menorah lighting from seven thousand miles away, visit the best doctors. If that's modernity, why not? But the fact that these discoveries didn't come about by themselves but are the fruit of free-thinkers including Darwin, Hume, Mill and other heretics - this the Chasidim don't understand and don't even recognize. When a Chasidic graphic designer sits with Coral or Photoshop and creats beautiful graphics, he might be so holy that he uses the Internet only for earning a livelihood. Then go explain to him that his art began with the painters of naked ladies in the Met, and he'll tell you that's not art, that's lust with a tie on."

Katle Kanye puts his finger on a weakness in Fader's depiction of Chasidic life as more in parallel with than in opposition to modernity. If we strip away everything that makes modernity a unique historical movement (the focus on the individual, the search for newness, the innovation in every sphere of life even to the extent of the abandonment of formerly universal truths), then what are we - or the putatively modern Chasidim - left with besides the name?

Nomi Stolzenberg, a professor of law at USC, is looking closely at these contradictions in the context of Kiryas Joel, New York - a town which has remained a predominantly Chasidic enclave through its inhabitants' creative, even contradictory, use of the principles of liberal democracy. How does a modern, liberal, secular political/legal regime enable Kiryas Joel to survive?
It would not be a surprise if Stolzenberg's answer ends up having a lot in common with the findings of Fader, Vaisman, and Benor: Chasidim make use of modernity as they finesse its significance.

Recently I got a phone call from a Chasid, who asked, "Can you tell me what I should read to introduce myself to secular culture?" He was adamant that he did not want to leave his community, but only wanted to know what books to read to get exposure to "other ideas." After learning about Chasidim and modernity, I now want to know: is he seeking to become more modern, more Chasidic, or both?

12/8/09

How liberal Jews can be as successful as Chasidim

I'm a modern Jew, trying to live in a way both authentically Jewish and culturally liberal. I enjoy ubiquitous technology and freedom of thought. My daughter can be a rabbi, a scholar, an artist, or something else entirely, unfettered by restrictions. But are we modern, liberal Jews still going to be around in a few decades? If my granddaughter will still be a Jew, what kind of Jew will she be?

The Hasids hold up their allegiance to their way of life, and none other, as an answer to these questions. No, I am not an authentic Jew. My Judaism is endangered by modernity. Liberal women are led astray by their freedoms. My granddaughter will be without any particular ethnic identity at all.

As a proportion of the Jewish community, liberal Jews are decreasing and fundamentalist groups (including Hasids) are growing. They spill over into neighboring communities and their towns (like Kiryas Joel in upstate New York) split at the seams. I worry they might be right. Perhaps liberal Jews are doomed to extinction.

Is there a way we can hold on to what we believe in and not be washed away by the surrounding culture? What can the Hasids teach us about being Jews in modernity, and is there anything about their techniques which we liberal Jews can learn from?

I've asked this question of myself time and again, because I am fascinated by Hasidim. I am by turns attracted and repelled by a Jewish group succeeding beyond all expectations despite predictions a few decades ago of their imminent demise, while motivated by ideologies that are in large measure strange and forbidding to me.

I feel a kinship to them for two reasons: one, they are Jews, and like them I am religiously observant (though in a way they don't recognize as observant); and two, I speak Yiddish. Because of this kinship, I have spent time with and developed meaningful friendships -- and some adversarial relationships -- with a number of Hasids, read a considerable amount of their contemporary literature, and devoted quite a bit of thought to the question of what liberal Jews can learn from Hasidim. I have done this while trying (in my Yiddish writing) to defend liberal Jewish ideology to Hasidim.

Wouldn't it be wonderful if liberal Judaism's ideologies and cultural institutions were to enjoy success and relatively ensured longevity, just like the Hasids, while keeping to our own liberal, Jewish values? At times I have thought that we should emulate Hasidic success by copying Hasidic strategies As a strange contemporary Jewish type - the Yiddishist - I have thought that we should, like the Hasids, retreat into an isolated community and talk Yiddish to each other. And I have thought that that might also be a solution to the difficulties of the other Jewish ideologies I identify with. If Conservative Judaism is most successful in scattered enclaves outside of New York (mostly college towns), why not found a Conservative enclave in the middle of nowhere? If we care enough about what we believe in, shouldn't we be willing to retreat behind the walls to keep out what will wash away our way of life?

The reason why this wouldn't work is obvious. We liberal Jews are modern, and we find value in that. Every interaction between Jewish and non-Jewish culture is not a source of anguish but the normal material of our life. It would be weird for us to choose to interact only with Jews, even if they were liberal Jews. That would take away our modernity.

So we can't build walls - or rather, if we are to be consistent with our ideologies, we can't. What should our survival strategy be? We can't set out to win the demographic war, as our lifestyle doesn't lend itself to strategic procreation. Perhaps (as many contemporary Jewish organizations seem to believe) we should make Jewish life as attractive as possible. Let's send young people to Israel, and maybe on the way to their paid vacation they will find meaning in Zionism. Let's try and create entertaining Jewish events which will pull in the disaffected and unaffiliated.

Such a strategy, however, becomes caught up in itself. If we are always reaching out with a Jewish liberal modernity, when do we start reaching in? What is it, after all, we want to preserve?

This is the most important lesson the Hasidim can teach us, even if we are unwilling or unable to build walls. Their way of life is successful, picturesque, rich, and in many ways meaningful, but its approach is one we cannot take. It is not for the obvious reasons that we are not Hasidic, and their ideology is not ours - that goes without saying. It is because of what their success teaches us about how movements can work: in spite of, not because of worries about survival.

What does this mean? Take two examples of successful, relatively recent (in historical terms) Jewish ideologies. Zionism was not predicated on the notion fhat the Jewish population of Eastern Europe would be nearly exterminated in the Holocaust. To be sure, many Zionist thinkers predicted that Diaspora Jewry was untenable, but as a general matter this claim has proven to be unfounded (the American Jewish community is in no danger of extinction). The success of Zionism has to do with the success of the ideology: Jews constructing a modern Jewish state in the Land of Israel. Whatever its flaws, that country does exist, thanks to Zionism. The ideology has succeeded. Even if Jewish communities around the world thrived, and Israel were comparatively small and insignificant in terms of Jewish life, its success would still be significant.

Similarly, Hasidism as a culture is not merely a means to an end of survival. Hasidim have large families and live lives of chosen isolation because they believe strongly that their observance of strict Jewish law is the only way to God's approval. If, through some demographic or historical quirk, this caused them suffering or disappearance, they would still feel this way. Their ideology - by their lights - would still be a success.

So I come to the conclusion that my worries aren't wrong, necessarily (maybe modern, liberal Jews are bound to decrease in numbers), just misplaced. If we believe that contact with non-Jews and a wide variety of ideas is beneficial to us, if we think that a spectrum of Jewish practice and culture is valuable, and if we own up to these ideologies with confidence, we can be free of the relentless demographic drumbeat which our own worries and the worries of our institutional demographers pummel us with. We can be confident, modern, liberal Jews, in other words, and succeed by doing what we believe in, whether or not our communities and adherents grow by leaps and bounds. We can be as successful as the Hasidim even if we can never be fruitful and multiply, or be as picturesquely isolated, as they are.

12/2/09

What bridges the gap between evidence-based medicine and the patient?

Under the withering barrage of recent guideline changes, doctors and patients alike have raised their hands in surrender. It seems like guideline group after group have changed their recommendations to say (more or less) the same thing: "[name of screening test here] should be discussed with the patient according to their risk profile."

We used to think that population studies ("big-E epidemiology") would provide us with the tools to fix health care. The drill of empirical science would become the Swiss Army knife of evidence-based medicine.

But something got in the way: inconveniently enough, that something is the patient.

A patient is not a population, but a unique individual with a one-of-a-kind combination of characteristics. So how to apply the population findings (or even the evidence-based recommendations) to the individual? As Karla Kerlikowske says in the latest issue of the Annals of Internal Medicine ("Evidence-Based Breast Cancer Prevention: The Importance of Individual RIsk"): "We urgently need risk models with better discriminatory accuracy . . . that can accurately identify individuals at all levels of risk."

So that's one way of bridging the gap. But there's another way which is just as central: making sure the patient is informed enough (about their own desires, even - about their own priorities) to make them a partner in decision-making. Because how can evidence-based medicine leap the gap from the journal to the bedside without the patient taking hold of it themselves?

11/30/09

Tasklist

dress in costume and act
out ancestral wars
embody concepts and live
the consequences
go to fancy restaurants
and steal fish forks
take relationships to the
next level, break up
make up, feel sorry
keep asking
and asking till my tongue
becomes a question
mark and quotes my ears

11/25/09

"Relaxed" guidelines and breast cancer awareness

I'm glad Hadassah is encouraging women to start annual breast exams at 40 and not follow the new "relaxed" guidelines. "Relaxed" is what I would call "evidence-based," but never mind.

The reason, shared with us by Allison Hoffman in Tablet's The Scroll, is that "Ashkenazi Jewish women are about five times likelier than everyone else to have the genetic abnormality that can lead to breast cancer." Perhaps Hadassah and the Susan G. Kornen Breast Cancer Foundation ("who has given Hadassah about $335,000 in grants for breast-cancer awareness") would care to explain to those Ashkenazi Jewish women why they are recommending annual breast exams that lead to unneeded biopsies and unjustified cancer diagnoses. Or maybe Ashkenazi Jewish women just don't care about those things?

One wonders if we need just as much awareness of false positives, the danger of unjustified diagnosis, and the unintended effects of massive screening programs as we do awareness of breast cancer. Maybe those of us who care about justifying medical interventions on the basis of evidence should come up with walks and ribbons and foundations too.

11/24/09

Nofrat Frenkel in and out of the spotlight

I appreciate the piece by Nofrat Frenkel in the Forward, but it is hard to square with what was said in her name on a Conservative e-mail list I subscribe to:

Sat, Nov 21, 2009 at 10:47 AM
[Shefa] Women of the Wall (WoW)

On Shabbat I spoke with Nofrat Frenkel and she asked to clarify:
1) She was not arrested. She was detained for questioning.
2) She did nothing that is not regularly done at WoW service. She has no idea what caused the police to suddenly intervene.
3) She would like the issue to drop out of the spotlight, so the police close the case without a trial and her (future) license to practice medicine is not jeopardized.
A good week to all,

I suppose it wouldn't be the first time that someone in the spotlight, for reasons not of her own choosing, is unsure whether she wants to be there.

11/23/09

A shocking statement in the medical literature

"Treating patients to lower than standard BP targets, 140-160/90-100 mmHg, does not reduce mortality or morbidity." (So says this Cochrane Review.)

11/12/09

What Google Translate calls my Yiddish blog

Hello Bargar

Language, talk, Ride On Flaflarii

A ray of sunshine

My house has many windows
I boarded them all up
Desperation's everywhere
Nighttime always stops

When a ray of sunshine
Hit my bedroom floor
Then for safety's sake I had
To board up my front door

11/9/09

When evidence-based medicine rules the land...

...and every provider everywhere knows exactly how to apply population-level data to the patient in front of them, and what recommendations to make, there will be times (to the chagrin of me and every evidence acolyte) when the patient says no.

Even worse, that patient might be right.

10/28/09

Getting Up and Going to Bed Song

There's a song in our morning squabble.
Bowl of cereal for a seer
Glass of milk for Melchizedek.
Put on your clothes with strangled oaths.
Bring your bit of everything.
The evening wants you to believe
How all rest leads to rightness
Your pillow stone straight at the head
Comforter smooth as eighty proof
Feet as warm as you can get.

Under sheets refrain is: breath by breath.

10/26/09

What does a Conservative commentary on the Shulchan Aruch need to have?

1. An introduction placing the SA in context within the general halachic philosophy of the C movement, answering (or at least approaching) such questions as these: is the SA normative? some of the time, maybe? or all of the time? (It can't be normative all of the time, because no law code is normative all of the time. Customs, other halachot, and the march of history supplant numerous rulings in the SA.) If it's not normative, what is it?

2. A general answer to the question, "what do we do when the halachah is immoral" (e.g., when we are told that cheating non-Jews in financial dealings is okay so long as they don't know about it; or when it is assumed that women are not intellectually fit to learn Torah or participate in community life)

3, I am a cultural nationalist, so I think any such commentary (okay, I'll bite: maybe the one I'll try to write) needs to be in Hebrew. Or Yiddish. But English is fine...just so it is an English thick with references and cultural suppositions of the halachic/midrashic/Jewish religious literature. But *at the same time* whoever comments needs to be able to make reference to the social and natural sciences without being apologetic or succumbing to special pleading.

Anyone for rising up in the morning in the lion to do the Divine will....Convo-style?

10/25/09

Where is the Conservative Shulchan Aruch?

I was talking with a friend about all manner of things (mostly his research, which I do like to hear about). We got onto the topic of the Chofets Chayim, and I mentioned that whenever I learn the Shulchan Aruch, it's as if the Chofets Chayim is commenting on another work entirely, so different his world view seems from that of the Mechaber and the Rema.

So I thought: where is the Conservative commentary on the Shulchan Aruch? Shouldn't there be a maestro halachist somewhere in JTS (or UJ, or Schechter) that can bestride the centuries, bringing Caro's mystical magid into our studies?

Failing that, maybe the lay public can try, in the spirit of open source Judaism. An act of massive chutzpah? Sure. But what of worth was constructed without it?

10/21/09

How do you define religion?

Check out this discussion from philpapers.org where Jim Stone of the University of New Orleans tries to do just that.

10/19/09

This blog is very nice

This one, here. It is about books of poetry. You will notice that the blog's title is booksofpoetry (or alternatively BOOKS OF POETRY) so you won't forget it. Nor should you. Go read it.

10/12/09

I wouldn't say no, either

I keep trying to think who besides Michael Wex they could get to do the Yiddish for Chabon's Policemen's Union, but I can't come up with anyone else.

Oh, except...

10/6/09

Does stress cause hypertension? A view from the real world

If you ask a doctor, they'll say that stress doesn't cause hypertension ~ or, at least, they will analyze "stress" in biomedical terms (catecholamines and what not). But every clinician has had the experience of patients who are sure that they know when they have high blood pressure: it's when they get stressed.

In a thought-provoking talk at the International Conference of Communication in Healthcare (which I return from tonight), Barbara Bokhour (from Boston) et al. helped reframe my experience with their analyses of interviews done with patients with uncontrolled hypertension. Patients have their own models for hypertension (psychological stress playing an important role in these) and they take action to self-treat, by trying to reduce their stress.

Among the researchers' interesting findings was that patients might be etymologizing hypertension into "hyper" + "tension": if you have high blood pressure you must be really tense.

I had two thoughts about this. 1. Why not co-opt these patient models, telling them that anti-hypertensives reduce stress (on the heart)? Not entirely deceptive. 2. What if we just started calling it "high blood pressure"?

10/1/09

Galgal ha-machzor

The Rabbinical Assembly continues to be liturgenic.

Before Yom Kippur I got a look at a PDF (uncorrected, not for distribution, highly radioactive, not proofread, and under the strictness of Conservative cherems. Also available here) of the new RA High Holiday machzor, scheduled for publication in May, 2010.

Readers of this blog (hi, Dad) might know that I have bitched and moaned in the past about the Conservative machzor, vintage 1978, with its worst translation in the world and assorted theological missteps (confessing our sins against the victims of the Holocaust!).

Features of the new machzor, or at least what I saw of it, that I like:
  • Retaining (or reviving) the double-acrostic al-chet.
  • Revising and in many cases improving the English translations.
  • Including piyyutim (liturgical poetry) from a variety of locales and centuries, including some not familiar to me (your machzorage may vary).
  • A marginal commentary that is helpful but not in your face. It's not as scholarly (read: nerdy) as I would like, but I'm not sure that was their goal.
  • A great acrostic alternative to Avinu Malkenu.
Features I could do without:
  • Tortured & corny rationalizations for including the imahot in the Amidah. If you include them (I do), then do it, and include the option in the machzor. But vague yeasty talk about "listening to women's voices" won't move anyone anywhere but away from inclusion.
  • Keeping the silly English acrostic as a translation for the al-chet. It's still silly.
I'm looking forward to seeing the final version.

9/29/09

I don't know why I'm in the hospital!

Continuing to tweak my thoughts about doctor-patient diagnostic discordance (i.e. doctor says: she's in the hospital for X; patient says: my doctor told me I'm in the hospital for Y), this time for the International Conference on Communication in Healthcare to be held Oct 4-7 in Miami Beach. I will be heading to the sukkah, not to the surf (I'm arriving 10/5 if anyone wants to look me up), but I am looking forward to it nonetheless.


I'm also working on an application for an AHRQ grant on the same topic so I can reproduce my Bellevue pilot study at the Johns Hopkins Hospital.

9/15/09

Multiple diagnoses ... and multiple diagnoses

I feel certain scruples about blogging about my new workplace (Johns Hopkins) - I suppose that's a good thing. I like it, is what I'll say to start.

The patients are different. Half of them are very well educated and knowledgeable about their conditions, bringing in lists of diagnoses.

The question I try to address - well, the question I haven't addressed yet, but would like to, is: do these long lists of diagnoses serve a purpose?

I mean, there are lists and there are lists. Let's say

List 1. Diabetes, hypertension, coronary artery disease, depression, tobacco use
List 2. Cervicalgia, autonomic dysfunction, benign prostatic hyperplasia, degenerative disk disease

List 1 is more than the sum of its parts, and list 2 - not so much. Which doesn't mean the problems in list 2 are minor (every one has a right to think that their problems are not minor! why else would they come to the doctor?), just that the multiplicity of the diagnoses is less important.

How we spent our summer vacation

In pictures.

Возможно, поэма звучала бы лучше в русский?

A fellow Yiddish poet, Yisroel Nekrasov, translated one of my poems into Russian. Very nice of him, of course.

БЕЛОЕ НА БЕЛОМ

Хлеб с толстыми ломтями света.

Роженица расцарапывает кожу

От зуда.

Из чёрной раны

Вытанцовывает кость.

8/24/09

Fish organs for sale!

I suppose a Swedish fish libel would be preferable.

8/21/09

Ten reasons for health reform (with asterisks next to what Obama's effort might help with)

1. The uninsured.*
2. The uneven delivery of health care, which varies from hospital to hospital, region to region.
3. The money spent on ineffective care, using resources for the sake of those resources' continuing existence.*
4. The general unsustainability of expenditures.
5. The holes in our systems of preventive care*, care for immigrants, and care for non-English speakers.
6. The overabundance of specialists.*
7. The philosophical and ethical failures of the current medico-industrial establishment.
8. It all costs too much & we can't afford it (repetition of 4. for emphasis)
9. Other countries do it better.
10. If we give veterans, the old, and the poor evidence-based medicine (or at least we're starting to try) why can't we do it for everybody?×

8/13/09

Saving money while improving care

At the Health Care Blog, George Lundberg picks the following sources of savings, where comparative effectiveness research can help save money while guiding us to the most effective treatment. His confidence that screening mammography doesn't improve mortality seems misplaced (the data isn't clear, and the studies are difficult), and his jab at oncologists is impolitic, but otherwise this is a worthwhile list.

  1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.

  2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.

  3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.

  4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.

  5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.

  6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.

  7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

8/9/09

Australiana

I know a family man
devotee of the Kabbalah
who set out to cure the Chlamydia
that is ravaging the koala.

"All my creatures are precious,"
said the Maker of all people,
"but don't forget your esoterica
in the pocket of the marsupials."

7/30/09

A new bilingual anthology of contemporary Yiddish poetry!


Very exciting, and not just because I am represented (and helped with the translating).

"It is precisely [the] remarkable and idiosyncratic character of Yiddish, which bridges languages, cultures, 'worlds of geography and universal human spaces', that shines through this anthology of contemporary Yiddish poetry. Inspired by Peter Yankl Conzen’s poetry and his deep knowledge of the Yiddish literary tradition, Step by Step. Contemporary Yiddish Poetry brings together the voices of contemporary Yiddish poets from throughout the world."

Buy it here.

7/23/09

God, Doctor, and Patient: The Uncomfortable Hospital Triad

I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."

Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.

What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?

God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?

As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.

In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.

7/22/09

"This is Dr. Berger. He is visiting Australia to see what a modern medical system looks like."

I spent the day enjoyably. I gave a talk this morning to the folks at VMA General Practice Training, one of a number of provider training centers throughout Australia. (Recently - within the past decade or so - the Australian government has decentralized the training of general practitioners, formerly under the College of General Practitioners, in order to promote competition.) I had a feeling of being at home among people like those at the primary care program I just graduated from. Now, primary care doctors in the US are (with the addition of philosophical self-consciousness and their own advocacy organization) just like internists, while their equivalent in Australia is the GP. Australia is civilized because about half their practitioners are GPs. What struck me was how little difference there seems to be, on a brief first glance, in outlook and sensibility.

Then this afternoon and evening I have been shadowing the clinicians at Parkridge Medical Centre in Melbourne. Besides the obvious differences (namely, that Australia has a "modern medical system" with universal healthcare coverage) I noted, again anecdotally, a relative reluctance to spring first for the pharmaceutical solution, something I know I did as a resident (mere weeks ago!).

7/19/09

Hacked!

I am sorry if my Facebook account is asking you for money, poisoning your cat, writing Ranolazine prescriptions, or performing other unspeakable activity. It were hacked, I tell you! I am trying to fix things as lickety damn split as I can.

But on one foot, some fun Melbourne activities (your mileage may vary):

Eating vegetarian pizza.
Comparing kosher baked goods.
Listening to my daughter sing songs learned in her (temporary but lovely) kindergarten (which they call "kinder" here).
Playing on the beach while discussing (with various people) Yiddish poetry translation, bioethics, and an anti-realist view of scientific theories.
Appreciating the clang of the trams.

7/11/09

What makes it more likely for new prescriptions to be filled?

Recently, some colleagues and I at NYU looked at factors influencing first-fill adherence to new asthma prescriptions. Lower copay and oral administration were associated with greater first fill. See the abstract below and the full paper here.


Lower Copay and Oral Administration: Predictors of First-Fill Adherence to New Asthma Prescriptions

Background: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.

Objective: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.

Methods: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.

Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).

Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed through simple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

7/8/09

Is medicine a Jewish profession?: quote from a talk in preparation

if it is legitimate at all to say that medicine is a Jewish profession, it is not because that medicine is "more Jewish" than it is Christian/Hindu/African-American/etc. (that would be ridiculous) but because the ethical characteristics of the physician, while universally appreciated and able to be implemented in any culture, conform well with Jewish self-understanding, i.e. that Jews should be bayshanim (humble), rakhmonim (merciful) and goymlei khasodim (performers of deeds of lovingkindness).

7/5/09

Department of Welcome Exaggeration, Melbourne Edition

THE JEWISH CULTURAL CENTER AND NATIONAL LIBRARY KADIMAH

has the pleasure of presenting one of the world's most interesting
and well known lecturers visiting from the United States

DR. ZACHARY SHOLEM BERGER

two lectures will take place in the Leo Fink Hall at the "Kadimah"
7 Selwyn Street Elsternwick at 3 pm. on the following dates

"IS MEDICINE A JEWISH PROFESSION?"
12 July 2009 - lecture .n English

"WHY IS MEDICINE A JEWISH PROFESSION?"

26 July 2009 - lecture in Yiddish

Refreshments will be served.

7/1/09

Smoothing Over

problems pave
the potholes
with blacker
asphalt, so the
problems make
a swift
double bump
Not gone
Not gone

6/24/09

Ten Things I Know About Bellevue Hospital That Will Never Come in Handy Again

1. The closets that are always open across from the chemistry lab have signs that say "THESE DOORS MUST NOT BE LEFT OPEN."

2. Cocaine for sale!

3. There is only so much Valium in the hospital, and in a night with a lot of alcohol withdrawers, Bellevue just might run out. Then - the apocalypse. Or some other benzodiazepine, whatever.

4. What happens on the eighteenth floor, stays on the eighteenth floor.

5. During my intern year I got sick of people mistaking Bellevue, New York's oldest public hospital, for a psychiatric institution. Now I know the truth: Bellevue is a psychiatric institution which just happens to have a lot of medical beds too.

6. Sure you don't need to call an inpatient dermatology consult very often, but when you do, are they ever wrong?

7. No, the patient doesn't speak (Spanish, Chinese) - they're just (Filipino, Indonesian).

8. [insulting comment about a subspecialty or particular nursing station]

9. Sure you put the order in. You have to call too.

10. Now call again.

6/9/09

Evidence-Based Lobbying

Leaders of the medical-industrial complex wonder if the Dartmouth research findings might be a touch overblown. I dunno - maybe. But don't we doctors do a lot else based on much less evidence? What fraction of hallowed medical practice is based on no more than class IIb recommendations?

Heck, I'm ready for New York to get less medical money. I don't think the kinds of places I'd rather practice are the ones that are overspending.

5/21/09

Super Jewish Historical Prediction Game: Female Modern Orthodox Clergy Edition

I. circa 1980

Cathy Conservative: Women can be rabbis!
Joe Modern Orthodox: Pshaw!

II. 2009

Joe Modern Orthodox: Women can...umm...kinda be rabbis!

III. 2025

Joe M.O.: ___________ (fill in the blank)

5/15/09

Evidence based medicine: pragmatic, objective, or authoritarian?

In the spring issue of Perspectives in Biology and Medicine, Maya Goldenberg dissects the contradictions of evidence-based medicine (EBM). (I found the article through philpapers.org, which I didn't know about before.) On the one hand, EBM's commitments to pragmatism
are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.

On the other hand, EBM lays claim to the marble statuary of objectivism, which is problematic.
[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.

But EBM's hierarchy of evidence, with the randomized controlled trial (RCT) at the top, rests on shaky grounds itself:

From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.

EBM's certainty in its own objectivism leads to a blindness: "[t]he hierarchy of evidence is the point at which evidence-based methodology can be charged with authoritarianism." There are some juicy accusations in this article, which I didn't know before, about the financial relationship between EBM "producers" and the editorial boards of certain journals, e.g., BMJ.

However, in her conclusions, Goldenberg is fittingly pragmatic:

In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.

5/11/09

Chasidic Yiddish blogger Katle Kanye on the swine flu

Original here. Translation mine.
The truth is that we Chasidim haven't been so impressed by the swine flu from the beginning. Yes, it's gotten to South America, Europe, and even Israel. But that sort of thing usually doesn't interest a Chasid too much, and a "God have mercy"or a "it shouldn't happen to us!" can take care of it. So folks in New York have gotten it too? I assume you're familiar with the verse "and all the children of Israel had light in their dwellings"! And which cheder pupil doesn't know about the plague of blood when the Egyptians bought water from the Jews - so what's the difference here? ...They said about AIDS that it would eat up the whole world, but like the lice in Egypt it stopped at the Chasidic zip codes. Just like the miracle of the shemittah farmers who clearly see their blessings compared to their neighbors, all the maladies I visited upon Egypt are not seen or found among those who are meticulous in their observance of commandments both major and minor. So much the more so in this case because we don't eat the flesh of pigs - their hoof is cloven but the cud they do not chew - and we're in the month of Iyar, which stands for I, God, am your healer.

The catastrophe is though that - whether it's really true or they're just saying it - two yeshiva students from Mir got it. Oh my teachers and rabbis, death has risen to our windows, come to our palaces and the Angel of Death is attracted to white shirts and black hats too. Now it's a tragedy. I know the experts say that it's easier to get infected on the train than it is from a Chasid's achoo on the other side of the Mediterranean, but what do the experts know? They say the world's getting warm but the kutchme sellers aren't yelling for a bailout. When Chasidic young men get it it's a whole other story. It's our concern now, so we need to get in touch with the Chasidic doctors and move mountains.

Nevertheless, as they say, in all labor there is profit, or as the goyim say, every cloud has a silver lining. A truly God-fearing Jew feels a spiritual satisfaction, a feeling that we're not left out, we're on the guest list too. Leave it to the Jews: if there's something to pick up in the world you can bet that we won't be left behind. We might look different but there's nothing we don't have. We'll get there. We won't just get there, we'll make the whole business our own by giving it a name. Make a mishebeirach, change pig to Mexico, and confuse the devil just like we do on the eve of Rosh Hashanah... from a swine's flu you can make a silk purse, or a shtreimel.

5/3/09

What are we to learn at the bedside? A re-examination of Verghese's essay "Culture Shock"

Abraham Verghese's essay "Culture Shock" (pdf) made a lasting impression when I came upon it last night during a quiet period at work. He writes beautifully about the real patient, with all his spots and signs - as opposed to what Verghese calls the "iPatient," the simulacrum found inside the electronic medical record but nowhere else.

I do realize that we residents, no matter where we train, hone our skills on the iPatient's indices ("The iPatient's blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed") while getting ever farther away from the bedside physical exam done on the real patient. This article makes as powerful a case as any I've read for the re-centering and re-honing of my skills, and it comes at just the right time, when I have the chance to make a transition to be the kind of doctor I want to be. 

But Verghese is confused in his defense of the physical exam - he doesn't know what rationale he wants to focus on, or how he feels about physical diagnosis as justified (or questioned) by evidence-based medicine. Here he is in one place:
If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.
This is the argument from efficiency, or maybe from diagnostic rigor - exceeded somewhat by Verghese's clear affection for the physical exam as a pedagogic and maybe, even, an esthetic, cultural, and moral tool. But it's not clear whether Verghese believes that the physical exam does improve diagnosis or efficiency. Just paragraphs later, Verghese takes another turn:
Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a larg pleural effusion is worthwhile in and of itself.
The physical exam's actual use in diagnosis is again feinted toward, but without making a real case one way or the other ("we need continued study in this area," the academic physician's classic copout that I know I use at the end of every article I write).

Near the end of the essay, and most confusingly, Verghese takes yet another tack when describing with understandable pride the teaching of the bedside physical exam he coordinates with his chief residents:
We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart.
But this comparison is double-edged. If a finding on the physical exam is like a biomarker, then it is like any other diagnostic test, which can be ignored, re-interpreted, or even not tested at all based on the prior probabilities the physician approaches the patient with. Perhaps - given the patient - I might prefer the information given by X-ray to my own physical exam. Or maybe, given the vagaries of varying echocardiography reads, I might privilege my own cardiac exam.

This is why I find Verghese's essay, though moving and personally challenging to my own too-ingrained love of EHRs, to be ultimately unsatisfying. If medicine is a culture, it changes. If the physical exam is to be a practical part of the diagnostic art, and not a relic, it too must change. Let's find out which parts of the diagnostic exam work, and why. We know that no physician does the "head-to-toe exam" for more than a fraction of his or her patients, so which parts should be done when? When is it useful to look for Roth's spots as a diagnostic adjunct rather than as a fascinating bedside pedagogical tool of limited clinical import? (Probably rarely.) Given our limited time with patients, should we not build rapport and understanding by asking more detailed histories at the bedside, rather than indulging in percussion of parts which have no diagnosis to yield up? 

I take Verghese's wisdom and his eloquence but I look for rigor elsewhere, trying to spend my time with the patient in ways that build our therapeutic relationship and find a true diagnosis efficiently.

5/2/09

Activism and Jewish Science

The folks at 36 Under 36 are an accomplished bunch, but The Jewish Week is laboring within a limited definition of Jewish activism: viz., stuff which yields a creative product or institution immediately appreciable by the Jewish lay public. But (with the exceptions of Ethan Tucker and Adam Kirsch) what this definition leaves out is the intellectual effort of Jewish academia, which never got anyone to make aliyah or become a mikvah habitué but - for all that - is of value. I wonder if the assumption might be that activists Act, while pure intellectuals don't. But that would be wrong.

Swine flu on one trotter

1. Even now no one knows how bad it could get. Or even (given that we don't know the real denominator of all cases) whether it's worse than regular old seasonal flu at all.

2. The limits of genetics: you can download sequences of many varieties of influenza A H1N1, but that tells you nothing about transmission and an unknown amount about virulence.

3. A prime example here of how people think of risks: the flu crisis is immediate and scary and thus available to them in a way that less immediate risks are not (car accidents, malaria).

4/28/09

The next word I say

Rivulets of now
gurgle into tanks of yore.
I stand and surmise:
nothing is more informative
than what we don't prepare for.

Dangers and dingers make
a finely textured catastrophe
or cancel out to a standstill:
listen! The next word I say

isn't a bad choice
to avoid oblivion. Your
warm room, your baby's bottle
are made possible in part
by what I write here.

4/27/09

She doesn't know why she's in the hospital?

I'm still thinking about an all-too-common hospital situation: doctor and patient don't agree on the reason why the doctors put the patient in the hospital. I'm giving a revised talk about it on Wednesday to my primary care colleagues. Comments welcome!

4/22/09

Why Yiddish Translations of Kids Books?

Hurting for translations? Come hear me talk tomorrow at 7pm, at Temple University Student Center (Philadelphia Center City, 13th and Montgomery) on why we publish Yiddish translations of kids' books. It's in English and free; books for sale!

Ask and you shall...what?

The USPSTF says every doctor should ask every patient about smoking. Guess I ask 90%. But the 95 year old? Really? The only thing I ask everyone is "How can I help you on this visit?"
Guess the typographics of SMS-blogging are not as transparent as I assumed. O for a stylus & clay tablet!
.."). I'm all for patient-centered care, and "male" is indeed too impersonal...but calling everyone "gentleman" is a touch unctuous, no?
When I was an intern every man in the hospital was a "male." Now they're all "gentlemen" ("This is a 56 year old gentleman with stage IIIA rectal cancer.

4/13/09

Three for three at Triptych

I had the good fortune tonight of hearing Yusef Komunyakaa, Hermine Pinson, and (who made the biggest impression on me) Aracelis Girmay. See the links at Triptych for information on these poets.

With regard to Girmay, I find myself in something of a spot, since she subscribes to an anti-Israeli orthodoxy ("apartheid" was a word she mentioned, in an introduction to a poem albeit not in a poem itself). She assumed that her audience was of the same belief, while I was squirming in my chair, distinctly uncomfortable and wondering if I should have taken off my yarmulke. But for her poetry! which busts every barrel hoop - I have to place my reservations with some poems over on one side, and my unfeigned joy with others at the center. Plus she was just so nice when she signed for me her new book, Teeth. You should buy it like I did. (She's a Watson fellow too, like I was; she sweetly signed her book: "Thank you for taking these into your home / to you, fellow traveler.")

A poem of hers:

FOR ESTEFANI LORA, THIRD GRADE, WHO MADE ME A CARD
for Estefani Lora, PS 132, Washington Heights

*
Elephant on an orange line, underneath a yellow circle
meaning sun.
6 green, vertical lines, with color all from the top
meaning flowers.

*
The first time I peel back the 5 squares of Scotch tape,
unfold the crooked-crease fold of art class paper,
I am in my living room.

It is June.
Inside of the card, there is one long word, & then
Estefani’s name:

Loisfoeribari

Estefani Lora

*
Loisfoeribari?

*
Loisfoeribari: The scientific, Latinate way of saying hibiscus.

*
Loisforeribari: A direction, as in: Are you going
North? South? East? West? Loisfoeribari?

*
I try, over & over, to read the word out loud.
Loisfoeribari. LoISFOeribari.
LoiSFOEribari. LoisFOERibARI.

*
What is this word?

I imagine using it in sentences like,

“Man, I have to go back to the house,
I forgot my Loisfoeribari.”

or

“There’s nothing better than rain, hot rain,
open windows with music, & a tall glass
of Loisfoeribari.”

or

“How are we getting to Pittsburgh?
Should we drive or take the Loisfoeribari?”

*
I have lived 4 minutes with this word not knowing
what it means.

*
It is the end of the year. I consider writing my student,
Estefani Lora, a letter that goes:

To The BRILLIANT Estefani Lora!

Hola, querida, I hope that you are well. I’ve just opened the card that you made me, and it is beautiful. I really love the way you filled the sky with birds. I believe that you are chula, chulita, and super fly! Yes, the card is beautiful. I only have one question for you. What does the word ‘Loisfoeribari’ mean?

*
I try the word again.
Loisfoeribari.
Loisfoeribari.
Loisfoeribari.

*
I try the word in Spanish.
Loisfoeribari
Lo-ees-fo-eh-dee-bah-dee
Lo-ees-fo-eh-dee-bah-dee

& then, slowly,

Lo is fo e ri bari
Lo is fo eribari

*
love is for everybody
love is for every every body love
love love everybody love
everybody love love
is love everybody
everybody is love
love love for love
for everybody
for love is everybody
love is forevery
love is forevery body
love love love for body
love body body is love
love is body every body is love
is every love
for every love is love
for love everybody love love
love love for everybody
loveisforeverybody

Cuss like an Israeli

With this handy article (in Hebrew).

Thanks to a helpful Louisville reader who probably will not lose sleep if he is not mentioned by name here.

4/5/09

Evidence-based medicine meets the Times

A great post by David H. Newman (an ER doc) on their Health blog, Believing in Treatments That Don't Work.

A problem, though: occasionally, instead of practice not following evidence, the evidence lags clinical practice (there are clinical problems which haven't been studied yet, or at least not in the population the clinician is seeing), and then it's very difficult for the doctor to know what to do. Then he or she has to integrate different kinds of clinical evidence.

Evidence-based medicine is everything, but it's not the only thing...

Life-saving duties and the "observant" doctor

In the Journal of Halacha and Contemporary Society (LVII - love the classy Roman numerals!), Howard J. Apfel, a pediatric cardiologist, rabbi, and teacher at the boys' high school of Yeshiva University, presents a thoughtful and detailed article entitled "Life-saving duties on Shabbat: switching call with a nonobservant Jew."

This being an Orthodox journal, there are a number of premises I don't agree with. The first(implied but present nonetheless) is that all Jews are either "observant" or "non-observant." In reality, while Jewish religious observance is a spectrum, what the author means here by "observance" is membership in the [ultra-?]Orthodox community, which has certain sociological criteria. Thus, while I'm an observant doctor, I am not an "observant" doctor for the purposes of this article.

The second premise is that contemporary halachic decision-making must be attendant on the gnomic public pronouncements of great ultra-Orthodox rabbis. We've talked about this.

But putting those premises aside, there's something else to talk about:

"[W]hile the non-observant doctor or soldier fully intends to save life, they are also deliberately doing the prohibited actions involved [on the Sabbath] for personal gain (for example to receive their pay, or to avoid being fired or prosecuted) as well."

I won't go into the details of the halachic argument, but I will point out that the understanding of motivations here is deficient. Doctors, soldiers, and other people walk around with multiple motivations, some of them primary, some of them secondary. Some of these motivations recede into the background and on occasion cannot even be recognized by the person so motivated. But in the majority of cases, people aren't motivated this way at all! No one thinks, "I need to put in these medication orders or I won't get paid"; "if I don't go check on the patient, I'll get fired"; "if I don't put in this IV, someone will sue me successfully."

Well, maybe some doctors do, but not the good ones.

3/23/09

How could someone not know why they're in the hospital?

As it happens, I gave a talk on that topic today. It involves some ongoing research of mine. Have a look!

3/19/09

Miscellany (or: Dead animals; The Chinese Channel; MI and Racism)

I'm such a Mishnah nerd. Starting a new tractate gives me a rush. And I've never really learned Zevachim before. (Look, Zevachim 1:2 isn't paralleled in the Tosefta at all?!)

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Verizon FIOS didn't mean much to me until Celeste figured out that we now have Chinese TV. 很不錯!

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What are the factors associated with racial differences in myocardial infarction outcomes? They have more to do with baseline cardiac risk and hospital factors than with treatment received. So disparities - as we all thought, I guess? - are pretty far upstream. To put it crudely but not inaccurately: African-Americans are poorer, and their hearts are sicker, even before the first troponins are drawn.

3/9/09

Snackbag Poetry

Enemies run harum-scarum!
Today at last we have our Purim!
Tie the noose in several knots.
Joking: Excess. Drinking: Lots.

[Yiddish/Hebrew doggerel here.]

3/5/09

Things are looking up!

Just a couple of hours ago, while buying some Fritos, I heard the President of the United States say live on national TV, "There need to be more primary care physicians."

Sounds good to me!

3/4/09

Operator, can you please page the Surgeon General on call?

The name of neurosurgeon and health journalist Sanjay Gupta was leaked in early January as Barack Obama’s choice for Surgeon General. His selection has caused controversy, and the formal nomination seems to have been delayed by the search for a Secretary of Health and Human Services after the withdrawal of Tom Daschle. While we’re waiting for Gupta to be confirmed, we can ask: what exactly is the Surgeon General supposed to do, and in this administration whose watchword is change, can the office be more useful?

More in Clinical Correlations.

2/26/09

Doctoring while (not) intoxicated

It's easy to be high-minded about working Yom Kippur, but I just realized I'm working Purim - and I'm pissed.

2/17/09

Layers

Swimming up through layers
we see a cheese crumbled onto a
plate, a fat nut
gleaming in the center.
Suddenly in the black water
a large island.
Someone has already pinned
it with arrows.

Always takes a second
to figure out what I'm
looking at. No one says to their
lover: Honey, look what happened
to my body!

Today I pull up the scan
and everyone says Oh.
No one needs to point.

2/15/09

Does Massachusetts's health care reform work?

As Massachusetts’ Secretary of Health and Human Services, JudyAnn Bigby, MD, is charged with overseeing the health-care program which covers nearly all of the Commonwealth’s residents (nearly 98%) while costing more than anyone expected (about 800 million dollars in 2008). On February 4th, Dr. Bigby spoke at NYU’s Medicine Grand Rounds, where she summarized the approach and accomplishments of Title 58, the health care legislation passed in 2006. The program had several goals: improving access, reforming the insurance market, and (it was hoped) improving outcomes. Bigby gave clear and convincing evidence for the first two goals, while the jury is still out on the third.

More in Clinical Correlations.

2/12/09

Gained in Translation

Yermiyahu Ahron Taub is a multiple minority. He moved away from the ultra-Orthodox community in which he grew up; he is gay; he is a Jewish poet, and he writes in Yiddish, English and (occasionally) Hebrew. Nothing about him or his poetic persona can live in a single language — which is one reason, perhaps, that this poet (as a way station out of the ultra-Orthodox world) took a job as a painter’s model. Art can often work a transformation that can be difficult through language alone.

More in the Forward.

Rescued from the perils of covering the uninsured!

Thank God we aren't saddling states with the burden of offering Medicaid coverage to the jobless!

The House and Senate negotiators also agreed to scale back spending intended to help provide health insurance to the unemployed. The House originally proposed that the government subsidize 65 percent of private insurance, under a law known as Cobra, for one year after the loss of a job. The final deal calls for a 60 percent subsidy, and for only nine months. The House had also wanted to let states offer temporary Medicaid coverage to jobless individuals who did not qualify for Cobra coverage. That proposal was eliminated entirely.

2/11/09

Gebirtig, Improvised

On a chilly night a few days before Hanukkah, a quartet came onstage at New York City’s Bowery Poetry Club to improvise to the songs of Mordkhe Gebirtig. The pairing of Gebirtig and improvisation isn’t obvious: Can the works of the best-known Yiddish folk composer, shot to death in the Krakow ghetto, really be comfortably interpreted with the chief deconstructionist technique of modern music? But on second thought, the two do go together. Gebirtig’s creations are often mistaken for folk songs because he made sophisticated works of art that are clear, emotive and easy to understand. Similarly, the improvising musician sounds deep because he taps into the musical intuition shared by everyone.

Benjy Fox-Rosen is casual and deep, like most bassists. He came to New York in 2002 to study jazz, and has broadened his interest to include other alternative music. Yiddish music — “klezmer” is too limiting a term — is by now a member of the alternamusic constellation in good standing. There is jazz-inflected Yiddish music, hip-hop Yiddish music, punkish Yiddish music. Fox-Rosen’s quartet makes improvisational Yiddish jazz. Past decades have seen an upsurge in Yiddish music, with a solidification and dissemination of knowledge. So, there is now a repertoire, even an orthodoxy. Improvisation (which crosses boundaries) is something today's Yiddish-music listener needs.

But you shouldn’t get the impression that improvisation was the sole focus of the set. What I heard at the Bowery Poetry Club — sponsored by the Congress for Jewish Culture as part of the Kavehoyz series — was a vivifying concert of old lyrics in new bottles. First came seven Gebirtig compositions, favorites of the Yiddish musical repertoire and across the emotional spectrum, from tragedy to drinking song to savage pre-Holocaust irony. Fox-Rosen wrote the music to two of these (“Hayse Trer,” or “Hot Tear,” and “A Zuniker Shtral,” “A Ray of Sunlight”), and the effect (as always, with fitting musical settings) was to put the words in a new frame.
Next came a suite of four songs: Mark Warshavsky’s elegiac “Dem Milners Trern” (“The Miller’s Tears”), followed by improvisation, then Gebirtig’s “Hob Rachmones” (“Have pitty”), and then more improvisation. Finally, Gebirtig’s “Minutn Fun Bitokhn” (“Moments of Confidence” — defiance, that is, in the face of oncoming destruction) yielded to Avrom Reisen’s bitterly minimalist “Hulyet Hulyet Beyze Vintn” (“Howl, Howl, Raging Winds”). The songs are diverse, as their titles make clear, though the listener unfamiliar with Yiddish music of this vintage (that is, prewar) might be forgiven for finding it all a touch sentimental. In particular, when I heard “Hulyet Hulyet” I couldn’t get out of my head the version by Daniel Kahn & the Painted Bird, driving, nasty and wholly Reisenish in its forthrightness.

But Fox-Rosen’s versions have their own inventive charms. I listened well that evening, and I came away with an appreciation of the power of context. Improvisation, when done as convincingly as it was here, is a special current animating even overly familiar music. Improvisation and composition combined are the best of both worlds.

Improvisation is about both the performance and the final product. Fox-Rosen, who is also a lead vocalist, managed to narrate in an off-the-cuff way, combining stories from his time in Argentina with impressions of old synagogues from a recent tour of Transylvania. Sometimes I couldn’t tell whether he was telling the stories to entertain himself or the crowd (“crowd” is an exaggeration here; it was 25 to 30 diehard Yiddish enthusiasts, all of whom I know too well). But I don’t think it mattered. His good humor was transmitted to the audience, which in turn was ready to follow him down musical byways.

Fox-Rosen was accompanied by Judith Berkson on voice and accordion, Noah Kaplan on saxophone and Juan Pablo Carletti on drums. I don't know if the rest of the quartet besides Fox-Rosen has any close connection to Yiddish music. This lack would be quite salutary for Yiddish music: It means, for example, that Gebirtig’s songs, now a part of the broad canon of alternative music, might find from an unexpected quarter another interpreter as fresh as Fox-Rosen in another 20 years. Thus (as the old Jewish idiom has it) will Gebirtig’s lips whisper in his grave, improvising a greeting for Yiddish musicians above ground.

2/10/09

Art is .... a doctor's name?

When people refer to medicine as an art, instead of a science, they don't mean "art" in the normal sense. They mean something like a craft. Otherwise in medicine we would have visionary crazies analogous to Joyce or Burroughs or Picasso. Or bad art.

Can health care act as an economic stimulus?

I'm scholar Googling and can't find anything. I don't know what the Obama Administration's argument is supporting their inclusion of comparative effectiveness research in the stimulus bill. Obviously I think CER is great a priori, as are EHRs, but neither save money in the short run. Do they stimulate the economy? Beats me - not my field - but I suppose in the sense of creating jobs, sure. (Funding research supports researchers, who buy bread, gasoline, and electricity just like everyone else.)

Note that this is separate from whether prevention and CER give good value for the dollar. Stephen Woolf claims unsurprisingly that they do, writing recently in JAMA. But the real point of his article is this: if you're going to ask whether prevention is worth the cost, you have to ask also whether (say) CTs, MRIs, and the whole whizz-bangery of technologized medicine is worth the cost too:
Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings. Whether those services are preventive or otherwise is not the point; what matters is prioritizing services that produce the greatest health benefits for the dollars spent. ... As a matter of economic security and ethics, it is inappropriate to debate the economic value of prevention while excusing the rest of medical care from such scrutiny.

Pots of money pretty please for primary care training and diversity programs!

Here's a call to action (read: e-mail petitioning) from the Society for General Internal Medicine. Unfortunately, I don't know explicit criteria for judging the stimulativeness of any given line item, but I would hope curing sick folks (some of whom work and make things!) would rank somewhere pretty high.

Later this week, a joint House-Senate conference committee will meet to reach a compromise on a massive economic stimulus bill. The House version of that bill includes $600 million for primary care health professions training, diversity and nurse education programs. This would double the current level of funding, a long needed beginning to healthcare reform.Unfortunately, the Senate version of the economic stimulus bill does not include funds for these Title VII primary care training programs.

Please contact your two senators and your representative today! Lawmakers need to be convinced that the compromise bill they send to President Obama must include $600 million to help ensure the supply of primary health care providers, namely internal medicine, family medicine, pediatricians, dentists and nurses.

2/3/09

Bless the sun?

This seems a wonderful & fertile example of aggadic creativity, but I wonder how I am supposed to react to the bracha when (a) I don't think it makes sense to speak of the sun returning to the same place in the heavens, given that the heavens have changed considerably since creation; and (b) we can't date creation to any particular date, and certainly not the zero-date postulated by Chazal. So do I:
1. Quash doubts nusach ha-ortodoksyah?
2. View it as a pretty metaphor albeit astronomically impossible?
3. Give up astronomy, especially belief in a universe billions of years old?
4. Or maybe just omit shem ve-malchut?

2/2/09

Creatures

Here are the creatures I think about:
Stammerers that like to kiss,
Poets dead a century,
Prophets.

I run headlong into pigeons
To catch them lifting up
As if they are lifted.
An aged hand might be the closely stamped card
Of a worn library book.

It's easy not to think
Of the elephant. I just imagine
What you want and go do it.
Hot tea,
Sweetened with fake sugar.

1/29/09

1/28/09

"Women like women's things": Chasidic Women's Magazines

The name mentioned most often in the November issue was not Obama but Hashem. This is Binah, "the weekly magazine for the Jewish woman."
Read my article in Nextbook. There's even one reader comment already, about a zillion percent more than I usually get here (what's 1 divided by 0?)! Sure, the comment doesn't make much sense (something to do with the "liberal-arts outlook," whatever that is supposed to mean), but that's the price of free speech. 

1/25/09

A penny of prevention is worth a pound of cure?

I wish Obama all the best, and I'm excited that health care reform is being contemplated as one of the first orders of business after the stimulus package is passed. Prevention is being touted as a big healthcare money saver.
Link
But prevention of what?

1. Prostate cancer by PSA screening. (Whoops, early detection doesn't decrease mortality.)
2. Breast cancer by self-exam. (Whoops, ditto. Mammograms work, though.)
3. Colon cancer by colonoscopy. (Right-sided cancer might not be caught by colonoscopy.)
4. Pneumonia by vaccination. (Whoops, maybe not - except in high-risk groups.)
5. Heart disease in women by estrogen replacement therapy. (We know how that turned out.)
6. Cancer by vitamin ingestion. (Whoops again.)

So not only is prevention very unlikely to save significant healthcare money, but we have to make sure we're actually preventing what we set out to prevent.