Authentic values and real interests: Daniel Sulmasy's new model of end-of-life decision making

These are very brief notes from a talk I attended at the Osler Center Day this past Friday.

Sulmasy presented what he calls the traditional tripartite view of EOL decision making, each part of which suffers from significant defects. The top of the pyramid, the optimum, is customarily held to be the living will (LW). However, living wills are both too vague ("no heroic measures") and too specific ("CPR but no counterpulsation"), involve interpretation of texts, and aren't done by most people anyway (current living-will rates are about 15%, per Sulmasy).

The next best choice is held to be substituted judgment (SJ). Sulmasy pointed out that SJ (a) places significant psychological pressure on families, with attendant sequelae; (b) is difficult to instruct family members in, because its meaning is not really clear; and (c) isn't what most people, when asked hypothetically, want to happen when they're non compos mentis anyway.

Sulmasy pointed out - interestingly enough - that the legal pedigree of substituted judgment goes back to English law, when questions like "What happens when a crazy person inherits a bunch of money?" or "Can a lunatic be made to donate a kidney?" had the courts looking to SJ for answers. (The case law had names like A Lunatic, but I can't remember the references. The big Columbia Law reference which got the SJ ball rolling in the 70s is here.)

Then at the bottom of the heap is Best Interest of the Patient, which no one likes because it's (a) paternalistic and (b) difficult to discern (Sulmasy didn't give (b), but I think it's obvious).

Sulmasy made the point that while LWs are supposedly optimum, everyone acts like Substituted Judgment is better.

So what's the better model? Consider the patient as a person, says Sulmasy, and think of the authentic values of that person. Then take into account, further, the clinical facts of the case. Then, keeping in mind the real interests of that person in light of their values and the facts of the case, try to come to a decision which respects all of those.

This is where my paraphase probably falls flat. But the key here that Sulmasy emphasized is (a) the neo-Aristotelian nature of his enterprise, i.e. emphasizing full flourishing; and (b) the skepticism of Sulmasy towards "Western, liberal" thinking which values autonomy above all else.

Another word for mustard

That's not how the word is pronounced, I hissed.

But the damage was done:

You tore the tongue out from every martyr

because you could not say the word for mustard

I taught you a week ago.

Torturing them over again

when we tell jokes about old men and fish

or different words for penis.

Am I wholly serious here? I'm not

serious enough. Reread the page.

Learn my name in the language

I want to speak. Silence

is the deadest tongue.

Great Literature, defined

My son* has developed a theory of what makes a book good. It is very simple.

1. A book is good if it includes a fire truck.

I tried to review my knowledge of world literature with this aesthetic in mind, but I discovered how little I remember.

Is there a fire truck in Ulysses? Probably somewhere (yes it does yes, says Google). The Bible doesn't make the cut, unfortunately, and I don't remember any hoses and ladders in Proust - not that I've finished him off. I bet there are a lot of fires in Sholem Aleichem, but in his time it was probably all about horses and bucket brigades.

This is going to be a big paradigm shift, I can tell.

*Who is two.

Larkin in Yiddish

This Be The Verse.

Translating even one sentence is hard! A case study.

A story by Chaim Grade (yes, her husband) excerpted in this week's Yiddish Forward doesn't seem all that interesting from a narrative point of view, or innovative stylistically, but it's lovely writing all the same.

Here's the first sentence.

אונטער די קאַלטע שטיינערנע געוועלבן פֿון קלויז ישן זיצן זקנים בײַ דעמבענע שטענדערס.

Unter di kalte shteynerne gevelbn fun kloyz yoshn zitsn skeynim ba dembene shtenders.

Under the cold stone vaults of the * the old men sit at oaken *s.

Kloyz yoshn is a macaronic phrase, yoshn meaning - of course - old in loshn-koydesh, and kloyz being a smallish prayer- or study-house. "Old study house" doesn't get at it, because yoshn is part of the name here, not an adjective. Maybe Old Study House, but that seems like we're talking about a Society of Friends meeting place. Venerable? Ancient? Neither of those work.

Shtender - that's a common Jewish, or at least Yeshivish word. I think that when Grade is talking about the skeynim (old men, for lack of a better translation) sitting at the shtenders, he doesn't mean the podiums that people daven at, but rather the bookstands that rest on a table. "Bookstands" doesn't sound right, though.

Foreign minister, an office that doesn't really mean much

But Beinart never mentions that Lieberman’s party won only 12.5 percent of the vote.

Right-o! Only 12.5 percent. Because that's . . . wait a minute! That's a significant proportion of the population! Voting for a racist demagogue! (Sorry! A "populist.")

More (if you care) here. From the always entertaining Commentary.

Adventures in Error Bars, Cell Phone Edition

So if you're worried about an exposure, and the exposure is difficult to measure (because, oh, you have no idea what the causal link would be between the exposure and the disease, so you don't know what you're measuring), and you keep doing studies about the exposure, you are eventually going to find a positive result (or weakly positive) because of the nature of chance.

That doesn't mean cell phones cause cancer. It means epidemiology is inexact.

Annals of Yiddish Lexicographical Video

From the talented Leizer Burko, a series of videos based on the life and work of Nahum Stutchkoff, thesaurus-maker and radio-playwright.

What's the benefit of diabetes screening?

Asymptomatic guy, obese, no high blood pressure. Do you screen him for diabetes? The USPSTF says the evidence is Incomplete. "Would a hemoglobin A1C [diabetes test] change your management?" I ask. Always my first question - I'm a skeptic to a fault. "Sure," comes back the answer. "If it was 8, you'd start metformin, right?"

Well, maybe. But that's the problem of the screen. If their number is 8, we put them in the Diabetes box. Then we "know" that we need to get their A1C at 7 . . .

But why do we know that? The evidence isn't so great that 8, say, is all that much worse than 7 with regard to clinical outcomes in an asymptomatic patient without evidence of micro- or macrovascular disease. Yes, if the number were 9, 10, 11, 12, then the answer becomes more and more definite, but you're going to start seeing symptoms somewhere in that range anyway.

[links to come, I hope]

I know I should be angry

We get comparatively low pay for more work than other specialties. The health care system is broken (even with the death panels!). But just today I saw two patients of mine in the hall, and I was happy to see them. I think they were happy to see me. And I get paid for this - a lot more money than other professionals get paid. Maybe I should get angry, but I'm not sure that would help.

Boing Splat Boing Splat

The fish is famous! (But buy it here, not on Amazon.)

X marks the spot

I take issue with Jay Michaelson's premise, well expressed though it is:

Fundamentally, religion works by saying that “if X, then things are okay."

Jay's a spiritualist, so wherever he drills in the rock of religion he finds spirituality. The gut shall rule forever and ever. But plenty of religious people actually believe X. They think X is the real thing. It's called eschatology.

You can psychologize their claims all you want, but there are people out there who believe what they say they do. It would be great if Locke's claim were in accord with the facts on the ground, and we could stick our heads in the sand until the nutsos go away. But - whoever the nutsos are - some of their claims are to be debated on face value. Gay marriage is great. The world was not created in six days. Our Israel policy is not determined by Revelations. And so on.

Tweet, whither wilt?

Half the time I can luxuriate in social media, buoyed by the multicolored sea of human interests & talents. The other half I scroll glumly through lmfaos and #wakeupyourfaceisonfire, thinking that all this is dust.

Hey! Over here! Poetry! Hey! Cold beer! Peanuts! Programs!

I feel like the Academy of American Poets' website focuses on poems and poetry, while the Poetry Foundation website is a bright poodle which has got hold of your pant leg. The Poetry Foundation twitter feed is a poodle which yip-yaps away distractingly at all hours about any text string which includes the word "poetry." A Google poodle.

Just because a thing can be well explicated

...whatever the thing is (poem, movie, course of treatment, political philosophy) doesn't mean it's any good.

Snake!

I turned the stick into a snake.
He said There must be some mistake.

I sang the suffering servant song.
He licked my heel with flicking tongue.

I rent my robe and loudly laughed.
He said I'd rather be a staff.

He crawled away and hissed So long.
I don't know what I'm doing wrong.

What happens if the Sabbath is boring?

Judith Shulevitz says in her new book - and everywhere else she makes her thoughts known - that the Sabbath is an island of tranquility, balm to the torn soul, etc., etc. Yes, but what happens when the Sabbath is boring?

I wonder if the Sabbathian (that's the person who can operate within Shulevitz's permissive, suggested boundaries) has a better answer to the question than the Sabbatarian (that's a more law-bound Sabbath observer, like me). The Sabbathian can say: if you're bored, that's the point! Boredom is something modern people try to escape from, while the Sabbath reminds us that boredom is the absence of things that should not be there anyway. We should not be buzzed and pinged, and their absence should leave space for a mysterium tremendum, not a grande ennui.

But - on the other hand - maybe the Sabbatarians have a better answer. If the Sabbath is boring - well, that's your fault! (Im davar reik hu - mikem: if it's an empty thing, whose fault is that?) The point of the Sabbath is finally eschatological, not sociological. There can be societies which are just, pure, and balanced, and wholly secular, without any need whatsoever of some artificial day of rest. (Indeed, secularists in America and Israel might legitimately scoff at Shulevitz's Rousseauvian naivete.) But no society - on the mystical Jewish view - can have the piece of eternity which the Sabbath affords. Only eternity itself, which is entirely Sabbath.

If you are mystical enough, that eternity could be vouchsafed even if you are on Blogger and Twitter and all the rest of them all the time. As long as you have a direct connection Upstairs.

Why matzah is tasteless

From the Sfas Emes (translated & paraphrased by your host):

How can the wise child ask for the reason behind a Biblically ordained law? It does say in the Bible, "He gives his sayings to Jacob, his laws and ordinances to Israel." There are cases in which one does not understand the reason behind a practice, but by the very practice itself one comes to know the reason nevertheless. Thus is matzah without a taste [טעם]* - so that it can fade into the background, leaving the eating of the matzah itself as the reason. Similarly, the last food eaten at the Seder should be matzah.

*This word can also mean "reason." - ZB

I'm sad...and I don't speak English!

Never fear! Though the New York City Department of Health and Mental Hygiene seems to have pulled the translated PHQ-9 (depression diagnosis) forms off their site, Albion saves the day.

A catalog of signs and arrows

I'm working on a catalog of signs, of arrows
with stubby beaks like sparrows,
resting places for gazes. Tomorrow

I'll make final edits and post, broadcast
to all my readers. Exact directions cast
a net of goals and safety. Last

night we mourned, drank, and fought.
Who died: it could be anyone. I ought
to tell you more and show you what I've brought.

Statins, heart disease, and risk - a conversation

What gives? How can someone with high blood cholesterol levels for 30+ years end up with clean arteries, if indeed there is any causation between blood cholesterol levels and plaque accumulation. ... Perhaps actual blood cholesterol levels have no cause of heart disease on their own a-priori. And, if any of these crazy hypotheses are true, then how can a health system prescribe drugs like statins so casually and routinely to anyone with cholesterol over 230? This is particularly true, when the long term side effects of such drugs must still be unknown.

Lots of questions -- some scientific, some health-plan political... But mainly I am looking for just straight talk on this whole cholesterol/heart disease issue.

You ask a lot of good questions. Let me paraphrase them for ease of presentation.

1. How do statins help in heart disease - through lowering the cholesterol level or some other mechanism?

It's not clear - this is one of those topics where the pendulum of the literature swings back and forth, and I can't say that I've followed every swing. Some hold that statins lower cholesterol, cholesterol causes heart disease, and that's it (though all the details of what the worst cholesterol particles actually are, and how they work their deadly magic, are yet to be fully worked out). Others think that statins are "pleotropic" - i.e. they work in multiple ways, e.g. by reducing inflammation.

2. How could you have high cholesterol and still have clean coronaries?

It's quite possible. I would imagine pretty common. That's why one of the biggest statin-related controversies hasn't really hit the lay press yet. It's all about when to give the medicines. Should everyone be on a statin if their cholesterol is above a certain level ("treat to target," or what I think of as the "statin in the water" approach), or should a statin be used only if a patient's risk of coronary artery disease is above a certain level ("tailored treatment")? A recent study in the Annals of Internal Medicine supports the latter, but no one really does this yet since the guidelines of the major doctor groups favor the former.

3. How do I know if I need to take medicine for cholesterol?

One way to think of it is this: statins lead to a reduced risk of coronary artery disease. Great. But this only matters really if your ABSOLUTE RISK, before statins, is something that you, or your doctor, are concerned about. If your 10-year risk of heart disease is 1%, and the statin reduces it to 0.1%, that's a 90% risk reduction, but maybe you don't care about a 1% risk. (I might not.) One way to calculate your risk is the Framingham risk calculator.

4, Do clean coronary arteries on a coronary CT scan (i.e. a low calcium score) mean I can't have blockages in the heart arteries?

No.

(When) Is the physical exam useful?

The hope that the physical exam might bridge the gap between provider and patient is natural and even salutary, but we should clarify why we think the physical exam is useful.

More at KevinMD.

How can patients and doctors talk about risk?

Check out this presentation (based on other people's research) that I'm giving tomorrow at the meeting of the Mid-Atlantic branch of the Society of General Internal Medicine. The Power Point version, prettier in its Microsoft way, is here.

A case of ... what?

Recently I was staying with relatives, which gave me the chance to read the New York Times in print. It felt old-timey. I chanced upon an article in Lisa Sanders's Cases series, whose tropes can be summarized as follows:

1. Woman faints.

2. The doctors can't figure out what's wrong with her.

3. Bad Doctor says it's all in her head:

A neurologist in New York carefully examined her and her now thick chart and pronounced definitively that there was nothing wrong with her and that she should try to relax and maybe take up yoga.

4. Good Doctor notices a few key features and makes the diagnosis:

Ledereich watched as the patient calmly sat up. “I know what you’ve got!” he told her excitedly. Her sudden collapse looked as if a switch had been thrown and all her muscles just turned off. Ledereich realized that although it looked like syncope, it wasn’t; she hadn’t actually lost consciousness. What she probably had, Ledereich told her, was something called cataplexy, and that meant that she also had narcolepsy.

So far so good. But the treatment didn't cure the attacks:

But for reasons that neither the patient nor her doctors understand, after about six weeks, [the fainting spells] returned. At first, just occasionally. Then almost daily.

Thereafter she is left to do (more or less) what the Bad Doctor suggested: integrate her new diagnosis into her life.

The patient has learned to cope with her unusual condition; she no longer drives. And when she feels the warning signs, she tries to alert those around her to tell them not to worry. She’s part of a small community, andby now, most know her well enough not to call 911.

There are implications left unexplored here. First: that diagnoses can be partially but not entirely therapeutic. As Up To Date says about cataplexy, "these symptoms are often improved by medications." Often, but not always.

Second, that so much hinges on how the diagnosis is conveyed. Bad Doctor indicated that the woman affected with cataplexy "should just relax" - an abrupt and unhelpful direction, but not, for all that, unfounded. There is a connection between anxiety and cataplexy (and other sleep disorders) remarked upon in the literature.

Finally, a question is left unanswered (and unasked) at the end of the piece. What does the patient know that she has? Does she identify with her diagnosis of cataplexy in a way in which she wouldn't identify with a diagnosis of anxiety or other psychiatric disorder? Does the partial failure of GBH to treat her cataplexy at all detract from her trust/confidence in the diagnosis? In short, what does the patient think of all this?

The Ten Contradictions of American Health Care

Uwe Reinhardt at the Health Affairs Blog points out the contradictory wishes of most Americans with regard to health care.

[A]s the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.

This year's Purim doggerel

Gallows humor can be lame. And

Dangerous, too. (See under: Haman.)

But what did his ten sons* do wrong?

"Their names rhyme! Put 'em in the song."

פּורים: אַ באַגרעבעניש די שׂונאים!

מאָגן: אַ קיכעלע מיט מאָן אים!

הלכתא רבתא: עד דלא ידע!

די איבעריקע: יאַדאַ יאַדאַ יאַדאַ!

Happy Purim from Zack, Celeste, Blanca, and Micah!

אַ פֿרײלעכן פּורים פֿון שלום, סעלעסט, בײלקע, און מיכל!

*And 70,000 innocent others.

What's that you're reading?

The below isn't mine. It's an excerpt from an article Why Live Without Writing by a famous German poet I've never heard of called Durs Grunbein, translated by Michael Hoffman and printed in the newest issue of Poetry. Except there is no such person, Durs Grunbein. There is a person "Durs Grunbein" whose "u" has an umlaut, but I don't feel like putting it in.

In his diaries, Hugo von Hofmannsthal brings up the story of a German officer in China who, following the Boxer Rebellion, participated in a penal expedition:

The officer sees a line of men sentenced to death, standing in a field. With his sword the executioner goes from man to man. There is no need for his assistants to tie or even to hold down any of them; as soon as it’s the next man’s turn, he stands there with feet apart, his hands gripping his knees, his neck stretched out, offering it to the blade. One of the last in line, still some way from coming due, is completely immersed in a book. The officer rides up to him and asks: “What’s that you’re reading?” The man looks up, asks back: “Why are you bothering me?” The officer asks: “How can you read now?” The man says: “I know that every line I read is something gained.” The officer rides to the general who has ordered the execution, and begs him for the man’s life for so long that he gets him off, rides back with the written acquittal, shows it to the officer in charge, and is allowed to go and take the man out of line. Tells him: “You’ve been acquitted, you’re free to go.” The man shuts his book, looks the officer in the eye, and says: “You have done a good thing. Your soul will have profited greatly from this hour”—and he nods to him, and sets off across the field.

If you read only one article on health care reform...

...then you've probably read it already, or you're never going to at all. But in case you haven't found that one article, hie yourself to The New Republic. There Harold Pollack has some clarity on the relationship between universal coverage and improved mortality

would universal coverage make people tangibly healthier? You betcha.

but says something else even more important:

there are other ways to save thousands of lives that are much more cost-effective than expanding health insurance coverage. We systematically neglect these other opportunities.

"With all that's forgotten I've long been obsessed": some of my obscure preoccupations online

A selection of my poetry in Yiddish and English is now available on-line through the good offices of Andrew Firestone of Melbourne and the site Yiddish Poetry. Recordings of someone else reading these poems will be uploaded soon. Please comment!

Inherit

I inherit
all knowledge left unwritten with martyrs
jokes that float to the edge of the glass
and pop, forgotten.

I speak ritual
storing emotion
for the controlled explosions
fusing life and death.

A thousand words from everyone,
each singing and dancing,
a little drop
in my labyrinthine neuroscape.

Books and Baltimore all Beautifully Brought to Blog

by the Baltimore Bibliophile.

The government of Israel mourns Sutzkever...not so much

Jeremy Dauber wrote a lovely piece for TNR (the print version only, it seems) about Sutzkever, though he skipped lightly over the problematic relationship between Israel and Yiddish:

To be the Yiddish poet of the State of Israel, winner of the Israel Prize and institutionally supported by no less than the Histadrut and Zalman Shazar, is no mean accomplishment, at a time when a commitment to “the negation of the Diaspora” and the negation of its mother tongue were standard procedure.

Nice use of the past tense, that ("were standard procedure," indeed). One would be more sanguine about the title "Yiddish poet of the State of Israel" if the State of Israel - or even the city of Tel Aviv - had bothered to send someone to the poet's funeral.

Only sing dinosaur songs with your children if they are learning about dinosaurs!!

From Music Together, which is sometimes too...earnest.

Music can be a powerful ally in learning nonmusical subjects because words gain meaning and energy when set to music. It is fun to sing songs about dinosaurs when children are learning about them. However, recent research in music-learning indicates that words can distract children from the music, particularly the tonal elements of a song. Therefore, songs without words are an important part of the Music Together curriculum. They allow children to have a more purely musical experience without being distracted by attempts to process language at the same time. This gives the tonal part of their music development a chance to catch up with language development, which is so much more emphasized in our culture.

The epic life of Avrom Sutzkever

Sutzkever’s work was outside the boundaries of school or ideology while benefiting from many of them. Like Marc Chagall, he was a virtuoso of the fiddle, the rose, the dove, and the rain, which in his hands became not cliches but inexhaustible possibilities. Even when the wellsprings of Yiddish culture dried up and it became ever narrower, Sutzkever found new depth in his craft, as if following his own map to buried meaning.

Read more in Tablet.

Mnemonics

The sleet on your cheek

is every forgotten face

The oilslick is a party

everyone remembered forever

overtaking the pure swan

of graceful forgetting

How should patients decide which hospitals are best for them?

Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?

Read more at KevinMD.

Doves, time, and pianos - together again

Three new translations of mine of three Yiddish poets - Avrom Sutskever, Yonia Fain, and Boris Karloff - are up now at InTranslation. Have a look! (And thanks to Alex Cigale for making me aware of the journal. While you're there, check out his translations from the Russian.)

Risky business

How can we use the best evidence to improve doctor-patient risk communication? That's the topic of my upcoming mini-workshop at the Mid-Atlantic SGIM meeting, my attendance at which is not just an excuse to go eat Indian food in Manhattan.

The latest news from Baltimore, in Yiddish

Public Yiddish television is made possible by the good offices of Youtube. And some kids who love the camera.

The cure for the common cold - what will it be like?

When it exists, it will be effective in 30% of people, and associated with intolerable side effects in another 10%. Thus doctors and patients, 60% of the time, will still have to hear the dreaded words: it's a viral infection, all we can do is try to improve your symptoms.

Progress doesn't march along, it sort of limps, gets lost, finds its way again, and lies down for a nap on occasion.

Future reasons for interrogation by the crack Western Wall egal-women arrest team

1. Tzitzit while ovarian.
2. Female etrogging.
3. Giving tzedakah while under the influence of X chromosomes.
4. Studying Torah . . . while female!
5. The tallit was too cute.
6. Singing. Singing is just bad. All singers should be arrested a priori.
7. Mitzvot are disruptive in general to the status quo. All the more so when done by women.
8. Arrest them all! Let Ovadiah Yosef sort them out.

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.

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.

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?

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.

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?

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

"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.

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.

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.)

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

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.

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.

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?

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?

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.

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.

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...

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"?

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.

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.

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.

Fish organs for sale!

I suppose a Swedish fish libel would be preferable.

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?×

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.

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."