Liking the ER

Is a guilt-inducing feeling. I shouldn't like divorcing patients' immediate complaints from their psychosocial contexts. I am in training to be a primary care physician, after all. Primary care should be a lot more than making sure someone doesn't have a heart attack or doesn't have appendicitis (or a cervical-spine fracture, or a really bad pneumonia, or shaking-raving alcohol withdrawal). It should be about treating the whole person.

And that's what the patients think, too. As we know (and our president celebrates), many people come to the ER because they don't want to, or can't, find primary care anywhere else. Thus they step in the door expecting a holistic approach to their problems, while ER docs still cling to their theoretical model of Emergency as triage and immediate treatment.

I could wax abstract here about the difference between deep medical knowledge - holism - and goaltenders' medicine - blocking the bad stuff: each of these has its place. I could connect this to bekius vs. iyun: the long-standing Jewish yin-yang between knowing a lot of Torah and delving deep into it. But there's too much at stake here hour-in and hour-out to allow abstractions. Patients are to be triaged either upstairs or out the door, and few of them (at least in Bellevue) understand how they are to have their chronic problems addressed.

I liked my first day because I felt in charge and in control (though supervised and occasionally countermanded, of course). But, on second thought, I should have tried to grab on to whatever jagged outcroppings of social context I could find in every patient's primary complaint. I should have tried to act like a primary care doctor even while doing the ER triage dance.


Making a Minyan: Women in Tefillin
Famous picture - second thoughts.
As I looked at the picture over and over again, I felt used. I didn't see myself in it, nor my mother, nor the other women I knew. Instead I saw the photographer's projection of what women in tefillin must be like: angry.
[. . .] We looked, to me, like a caricature of angry, scowling feminists. I called it the "Scary Amazon Women in Tefillin picture." [. . .]

For me, davening in tallit and tefillin has never been about women demanding the right to engage in rituals that had been limited to men. To me, the tallit and tefillin are how Jews should pray, and I had never, until I saw myself in that picture, seen them as an act of feminist defiance. [. . .]

But over time, something unforeseen began to happen. I started to get angry. I saw the female professors I admired in college not get tenure while their male counterparts were promoted. I saw the Jewish community blame highly educated working women for a declining birth rate. I saw women who had entered the Conservative rabbinate struggle for acceptance and for equality even 20 years after that historic decision. I saw my friends have babies and struggle to afford child care. [. . .]

I don't think [the photographer] was somehow prescient in his portrayal of us. I certainly don't think that he was predicting my own personal disillusionment. While I still think that his photo doesn't capture the essential love of Judaism, of prayer, of God, of ritual -- whatever it was that had brought each of the ten very different women in his picture to take on the mitzvot of tallit and tefillin, I now recognize myself in that minyan of defiant women, and that is a terrible disappointment.
Rahel Lerner in Lilith, Fall 2007. The piece (not on-line) is well worth reading in its entirety, as is the companion essay by her mother in response to the same picture.


Super Jewish Historical Prediction Game, Extra-Exciting Medical Education Version
Or: Even on Saturday

Since this thread at Pensées de Gil is still inexplicably active, let me make a prediction.

If "shomer shabbos residencies" catch on within the Charedi community (the Modern Orthodox and the Conservatives really don't buy into this notion), within a short time (twenty-five years?) there won't be any primary care providers coming out of the community itself. When that happens, either the quality of primary care for Charedim will decline, or a sensible posek will discover a remarkable heter: since most internal medicine programs these days involve very sick patients (and lots of them!) for whom pikuach nefesh is always on the agenda during their hospital stay; and since not working on Shabbos would mean disorder for the medical care of that community, and since Jewish doctors are a desideratum for a Jewish community [just as every community should have at least some doctors taking care of it which share its assumptions] -- well, then somebody is going to have to try and save some people in the hospital, even on Saturday.
Blogging the ER

For the coming rotation - starting tomorrow - I'll be in Bellevue Hospital's Adult Emergency Services department.

Besides managing patients on one side of the ER, the part of my role I am most eagerly anticipating (this is why I got into medicine, after all) is cutting off the clothes of trauma victims. I need to buy shears.


The New York Times discovers Yiddish

But nicely.


Terror in the Patient Encounter

Like meeting any new person, stepping into a room for a first conversation with a new patient is horrifying and humbling. All the insecurities that I've tamped safely down inside - after somewhere between a third- and half-lifetime of adulthood - come to the fore again: will they like me? Will we fight? Will I get out of this with what I want? will they get out of this with my hide? theirs?

Sure I am altruistic, sure I am aiming for good here. But the baseness of human relations has to be gone through over again (at least that's my experience) in every sphere, even in medicine - or especially. When you're sick, and I am intruding upon your sickness to define and delimit it (in the biomedical conception), why shouldn't it be an adversarial meeting?


End of Summer

Have you ever waited out all the sweatdays
till you're again worthy
of fresh pane-dew
cool as a beer bottle:
stand outside
face against the window.

When fall has left
its cold shoulder to you
again you have to get used to
the zealous seasons.

Winter which snows over every argument.
Spring which greens away others' desires.
And summer which sparkles and smiles and dries
and kills.


The sneezer himself
Li-achoo-atcha kiviti.

"[Talmud Yoma 88a: the breath of life in his nostrils teaches us that the essence of life is in the nostrils.] That is to say, the essence of the distinction by which one knows if the person who seems dead is definitely dead, or if there is still some breath of life - if there is still some breath in his nose there is still the breath of life, and if not he is definitely dead. One should not rely on other definitions. The reason for this, it seems, is that a person's soul leaves him in the way which it came, and since it came first through the nose, as it says in his nostrils the breath of life, so too is its exit also through the nose.

"It's possible that this is the reason for the custom to say "Asuse!"[Aramaic: Health!] to the person who sneezes (see Berakhos 53a and Rashi there). This according to what is said in midrash Yalkut, parashah Lech lecho, which indicates that until Yaakov people did not become sick before death but died suddenly by sneezing - a person would sneeze and his soul leave through his nose. This is also because the nose is the transit point between life and death, therefore when a person sneezes he is exposed to danger, and people say to him "Asuse!" Rashi writes in Berakhos: 'People are accustomed to say Asuse to the person who sneezes.' That is, only other people customarily say this to the sneezer and not the sneezer himself. This also implies that this is but a custom. But the Yalkut there maintains that a person is obligated upon sneezing to thank God - apparently then the sneezer himself is required to say some words of thanks. There are those whose custom it is to say 'I hope for your help, God' [lishuoskho kivisi adoynoy]. Apparently this is then a obligatory custom. Possibly one can say that the sneezer himself is obligated, but for others it's only a custom out of politeness [derekh erets]. But I'm not going to go into this further."

--Borekh Halevi Epstein, Torah Temimah on the Torah portion Noach


Sukkah poster with Conservative gedolim

Is there one? Can somebody make one?


The Great American Yiddish Novel
Dead, true, but also . . .

aborning here.


Resting on the eighth day.

I like our Diaspora's Shemini Atzeret, this shy orphan yontev. Rarely is it jovially nicknamed ("what are you doing for the Shmi?"). Its songs are stolen from contiguous holidays. Some people make a point on that day of sitting in the sukkah - because it's still Sukkot. Some make a point of not sitting in the sukkah - lest it get mixed up with Sukkot, because it's a holiday of its own. The uncertainty is charmingly Atzeretsian.

Come out from your cave, Shmi! We love you.

* * *

Even more interesting than the ongoing saga of How Dead Is Conservative Judaism (I guess it's hard to find a less interesting topic) is the tale of Arnie Eisen. This professor of sociology is now the de facto spiritual leader of the Conservative movement, meant to be the miracle worker of 3080 Broadway. This cries out for a superhero, The Sociologist-Rebbe (busy, Mike?):

Disciple: Oy, rebbe! Is this chicken kosher?

Eisen: Yankl, I find it fascinating that you are voluntarily submitting to my authority!