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.

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.

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.

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.

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.

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.

Well written and moving

This.

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?

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.