Too bad!

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

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

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

Bits of work, or: Passover primary-care cleaning

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

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

You can attend the talk too!

The dove wobbles slowly on

Ode to the Dove - a puttering translation continues.

Sutzkevers

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

So many notes!

Feast your ears on this collection of Pesach tunes.

Gee, thanks, I guess

Patrick Radden Keefe in Slate on Fujianese immigration:

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

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

Disgusting!

The first word my blonde daughter sought out
was Disgusting.

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

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

From permanent hesitation to mature skepticism: growing doctors

During today's lecture on decision analysis:

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

The Thirty-six Million Dollar Rectal Exam

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

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

Titsher!

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

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

ברוך מחיה מתים / Resurrection

Fafblog is back.

The only skill that matters in treating a patient?

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

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

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

The only skill that matters? How about:

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

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

Who pays standup tragedians?

Standing on a streetcorner
making children sad.

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

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

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

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

Happy Purim!

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

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

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

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

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

My minyan is a bunch of suckers

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

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

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

Medicosocial misfits

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

Cernăuţi/Чернівці/Czerniowce/Czernowitz/Tschernowitz/טשערנעוויץ

Yiddishists: fighting against inferiority since 1908.

Ode to the Dove

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

Competent to judge: Adventures in hospital ethics

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

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

Two sides of distress

I locked my friends in a cabin
and they love each other now.
Two sides of distress:
bloody sidewalk, topiary median.
I embrace their commotions
and have contracted them to draw,
in the dark cherry-ink of weavers,
victors standing over us.
Enveloped by perfect sight
I view the door clearly
but cannot feel for its handle.

Transformations, reincarnations, turnings, revolutions? - Gilgulim

Paris is beautiful and the Parisians' new Yiddish journal, Gilgulim, no less so. I'm honored to be represented.

The Poet Nauen

My friend Elinor (writer on baseball and cars and a powerhouse bal-tekiah) revs the engine on her new site.

The Resuscitational Imperative, II

On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.

But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)

My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.

The Resuscitational Imperative

It's not a technological imperative that drives the resuscitation of so many patients who (if you had asked them while they were of sound mind and not about to die) would rather not have been resuscitated, it's a philosophical imperative. Most doctors, in my admittedly limited experience, are biased towards doing something rather than nothing. Or - rather - biased toward the assumption that taking a positive action is more helpful, because more active, than doing nothing. But sometimes doing nothing is not doing nothing at all. Letting someone die can sometimes accomplish more than a breathing tube or a defibrillator ever could.

Who will have a mandate for a mandate?

Laszewski says it again:

I worry that both [Clinton and Obama] have cost containment strategies that would do little more then dent the continued escalation in health care costs and undermine both of their guarantees for affordable coverage.

Applied Nostalgia

My daughter and I had a fight last night (she's four; it happens) and we made up with me singing songs to her. The songs were in Yiddish, the language we speak at home. I was randomly singing whichever Yiddish songs happened to come into my head, and in the middle I thought: Isn't this ridiculous? The last three songs were a Bund ballad about blowing up a German ammunition convoy; a paean to Vilna; and the Partisans' Song. (I'm not usually so historical, but there you are.) It struck me, not for the first time, how unrooted my Yiddish language and culture is in my individual, quite ordinary-American-Jewish experience, and how an outside, Eastern-European-born observer might think that my use of these historically freighted songs is disrespectful, jokey, or obscene. (Some do.) What do I know of guerilla warfare, Jewish Vilna (I mean its physical bricks-and-mortar), or the routes of the Baal Shem Tov (the subject of another song)?

I used to answer "No" (a little hurt) when asked if my attachment to things Yiddish was due to nostalgia. How can I be nostalgic for something I wasn't born into? But that's precisely the point. We yearn for what we are not conditioned against. The tension of my ideological attachment to Yiddish is to be aware of the sunken past while not drifting away from the present in which Yiddish, very much extant, is quite un-Eastern European.

As for nostalgia, Jews couldn't get along without it. One of my daughter's favorite songs is Yah Ribon, whose last verse recollects the Temple. I never saw that either.

Youth! Youth! Yeth?

Yugntruf gets its yugnt back. (Hat tip: Byuralistke.)

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

Unintended IRB humor

From the directions to an IRB form I'm filling out:

Describe potential benefit(s), if any, for subjects participating in the research. If there are no anticipated benefits, this should be stated. [Note: Payment to subjects is not considered to be a benefit of research (see Payment section below)].

What is payment to subjects if not a benefit? (Shades of "Guinea-pigging.")

R and R

Regret
slips its noose
around the neck.

Remorse
sinks its tooth
into the corpse.

-Samuel Menashe

There I was today (by now yesterday) at Rizzoli's in front of the poetry section on the third floor, the elevator doors open and an older man calls out, "You're right in front of my book and you don't even see it!" He plucked it off the shelf in front of me. "I saw you read at the Harvard Club," I said to him. "Yes, the place was packed," Menashe agreed. "Three hundred people, and for some reason they didn't let me sell any books there."

Now I feel guilty I didn't buy his book today. There's always next time! (I did buy this one, which bears some distant spiritual relation.)

(Oh, and I didn't embarrass myself by telling him I'm a poet. Personal Dignity 1, Networking 0.)

Cool vs. High-Strung

Obama has been anointed the Cool Candidate on the strength of his spellbinding stemwindery. I feel my inborn contrariness (rhymes with orneriness) pulling me away from Coolness and toward hard-bitten (maybe even a little embittered) experience. Hillary, anyone?

A shot of panic becomes the rustle of glucocorticoid

Speaking of Kathleen Graber, she has a great poem in the newest issue of the New Yorker.

Nothing To Complain About Right Now

Every biting winter
was fall's soft cliché,
every aperçu
was a drunken bawl.
The queer tongue of our ancestors
is enlivened by the dead
and cobbled by curses.
I've been to countries
where that all lives on.
They saddle up their sins
and shout after the nag:
Improvement by degrees!

Unfair One-Off Ignorant Assessments, and Short Snippets of Poetry (without line breaks), From Last Night's Readers

Kathleen Graber: thoughtful, careful, with an intermittently epic reach, sometimes too grounded. I bought her book because I wanted to get the best impression of her poetry. "The form of stone is the form of attrition. It becomes itself by what is lost."; "[...]delicate rigid body of a bird[...]"

Catherine Pierce: concrete, domestic, honest. From her love poem to America: "America teach me how to strut . . . I love how afterward you roll over and snore like a locomotive before I even catch my breath."

Shin Yu Pai: I didn't write anything down to quote. I learned from her that the food industry is bad-bad-bad!

[Christopher Stackhouse read after Pai, but I must have been sleeping after my one beer; I don't remember what I thought of him.]

John Keene: earnest, professorial. "Driving at what is arriving, you must parse it out."

Ross Gay: by turns terrifying (not him, but his poem about unspecified violent little creatures) and nastily funny (about his friend's racist girlfriend). From the former: "the little one sat curled in a lump pretending he was dead"; from the latter (the girlfriend, white, speaks to her black boyfriend about how he is not "street" enough): "What does your Hegel say about funk? Your Dubois? / I only date hood."

Daniel Nester: Definitely the guy I liked most. Funny, self-deprecating. When I went up to him afterward and asked him if he was selling anything, his look of mild surprise and unfeigned delight was a pleasure to behold. "I brought one copy of a book of mine, if you want to buy it for five dollars," he said - so I did. From a poem: "When I said you were as old as my mother I wasn't trying to make you old or make you my mother. I was trying to give you details."

Talking about Jesus, II

The comment from "Hashem is Magic" got me thinking. Is it true that the injunction against "letting the name [of other gods] be heard on our lips" is meant to prevent our invoking them by utterance alone? Not quite.

There are two parts to the verse: first, that their names not be mentioned (ושם אלהים אחרים לא תזכירו); second, that they not be heard from the mouth (לא ישמע על-פיך). On second thought - are they two separate parts, or elaborations with differing emphasis of one central prohibition? This seems to be the central issue of the commentaries.

To summarize before getting into particulars: The Talmud grounds the whole verse in the prohibition of collaborating with idol worshipers. One does not swear by an idol (more precisely, a subject of avoyde-zore) because in that context one might come to work together with those who worship it. This short discussion is prefaced by another prohibition: one must not say to one's fellow, "I will meet you by the [name of idol]."

What the Talmud doesn't entirely clarify is the difference between לא ישמע and לא תזכירו. The Gemara connects the later phrase ("don't mention") to its disapproval of using an idol's name to identify a meeting place, while the former phrase ("don't let be heard") is glossed in the following way: "that one not make an oath in their name or carry out a promise in their name, nor cause others to do so."

The Talmud makes two other stabs at the meaning of לא ישמע על פיך. It could serve as a warning not to lead other Jews to sin in making oaths by idols; or it could be an injunction against collaborating in business with worshippers of avoyde zore. The latter opinion (of אבוה דשמואל), standing unchallenged, seems to be the final interpretation.

However, this approach does not square with that of the later commentators. For example, the Ramban says explicitly that any kind of mention at all, whether or not it has anything to do with idol worship (or collaboration with idol worship) is forbidden. (How Ramban understands the strength of this prohibition is unclear.) The Rambam, in his Laws of Idol Worship, cites the passage from the Talmud (nearly) verbatim. He holds that making an actual oath in the name of an idol is forbidden and subject to punishment by a rabbinical court, while a mere utterance of the kind mentioned by the Talmud is prohibited, but without explicit punishment.

The Sefer Chinuch, a compendium of commandments and their justifications, indicates that לא ישמע על פיך is a הרחקה i.e. an ancillary edict meant to strengthen a central prohibition.

The most sensible commentary, both true to the structure of the verse itself (לא תזכירו and לא ישמע על פיך are not different injunctions, but parallelisms) and the understanding of the Talmud (that the central prohibition has to do with swearing by avoyde-zore and collaborating with its practitioners) is that of the Shadal:

והוסיף לא ישמע על פיך, והוא כמשמעו לא יהיה שם האלילים נשמע על פיך, כלומר אפילו לפרקים ודרך עראי, אך לעולם הדבר למד מענינו שאין איסור אלא להזכיר דרך כבוד לתהילה ולתפארת או דרך תפילה ותחינה, ולא שתהיה הזכרת שם האלילים אסורה בהחלט, כי הנה משה אמר ( דברים ד' ג' ) : כי כל האיש אשר הלך אחרי בעל פעור וכו'.

"And [the verse] adds "it shall not be heard from your mouth," and this means that the names of other gods should not be heard from your mouth, that is to say even intermittently and casually. But of course the basic point here is that the prohibition is only that of mentioning [them] with honor and glory or in prayerful fashion, not that the mention of the names of other gods should be completely forbidden, since even Moses said 'every man who followed Baal Peor.'"

The above assumes that Jesus, for example, is a subject of avoyde-zore. I don't think this to be true.

The Yiddish FBI

The Forward's Allan Nadler favors us with a biting overview of the most decadent of history's rebbes. (Note that not all rebbes are decadent, and that Nadler speaks from a Misnagdishe viewpoint. He is biased, to put it mildly.) In the middle he says:

And so, Mayseh Ushits might be viewed as a cautionary tale for the alleged informant at the heart of today’s scandal. The Russian despots who persecuted the Hasidim and imprisoned their leaders were motivated by a lethal hatred of both Jews and Judaism, while the FBI is quite simply enforcing the laws of a just and uniquely philosemitic land (with the assistance, by the way, of a small team of FBI Yiddish translators, as a fascinating little footnote in the Bureau’s transcripts revealed). But this distinction is lost on the Spinker Hasidim, to whom the very idea of historical evolution is entirely foreign and whose main concern, now that the Rebbe is “free,” is to wreak God’s bloody vengeance upon the despised informant.

I could have been one of the FBI's Yiddish translators. Now the tale can be told (because no one cares at the Department of Justice whether I breach my little corner of confidentiality). There was a Web advertisement for free-lance Hebrew and Yiddish translators, so I bit. There was a written test (inexpertly typewritten, then mimeographed), featuring reading-comprehension questions based on passages that read like they were taken from pre-spelling-reform Forverts about how many troops were massing against what enemy on the northern front. ("Question 23. How many tanks does the enemy have rolling towards us right now? A. 1,000. B. 250. C. Those are not tanks. They are horses painted to look like tanks.") Then a telephone interview with a pleasant speaker of Polish Yiddish.

And then the lie detector test. At one point, the interviewer looked crossly at me and said, "Look, I really want to help you get this. I want to help you land this job. But you have to help me out. Why aren't you telling me the truth?" I think the problem was that I was associated with "foreigners" (e.g., the foreign-born editor of the Forverts) and so my answers to some questions ("Are you in cahoots with the Russkies?") might have been suspect. So I failed.

I'm not an FBI Yiddish translator . . . because I'm a liar.

Why not saying "Jesus" is silly

There are Jews in this world who are punctilious about not mentioning the names of others' (putative) gods. The verse [Exodus 23:13] they mention to support this practice includes the words לא ישמע על פיך, which is to say "[the name of other gods] should not be heard from your mouth." But these particular punctilieurs are careful not to mention these names even when such a mention could not possibly be interpreted as approval (much less worship) of these religious figures! Yes, there are people who really won't say the names Jesus, or Zeus, or (I guess) Zemu, and use made-up names like "Simcha [not Santa!] Monica."

That this is silly is well-known, but the reason has always been hard for me to articulate: until now. Language Log does a nice job dissecting the use-mention distinction.

Chinese for Doctors

You'd think that would be the title of an easily available book, right? But it isn't I thought it isn't. There's the Medical Chinese web site - very useful, to be sure - that some NYU medical students put together; I'm sure there are a number of other sites like it. Then, on the other end of the spectrum, are the thesauruses and dictionaries that are only useful for someone who already reads Mandarin fluently. But [I thought until now] there's no handbook that I could carry around.*

. . . I swear, I didn't start this post thinking I was going to advertise their book. But now they have one! I'll buy it tomorrow and review it here.

*There's Chinese Medical Chinese, which is euphoniously named but not relevant to Western medicine.

The literary virtues of Communism

Mikhail Krutikov in the Forverts:

The time when Jews in America felt unsure of themselves is probably over, and it's no longer necessary to feel ashamed of realistic portrayals of past Jewish life. American Yiddish literature was possessed of many artistic virtues which are impossible to separate from its predominantly left-leaning worldview: sharp anti-capitalist criticism, naturalism, and universality.

All the regulations: whose fault are they?

Whenever I complain about the bureaucracy attendant on every decision in our residency program - squashing us like bugs - the answer comes back: "Yes, JCAHO makes things hard for us." But the Joint Commission includes corporate members: the American College of Physicians, the American Medical Association, and the American Hospital Association. If my home institution, for example, thought that the JCAHO requirements were needlessly onerous, couldn't it organize opposition together with its fellow institutions? Or are we all just being sucked into a bureaucratic vortex?

The Moral Imagination

Steven Pinker's essay on the moral sciences (Adam Smith, anyone?) in the Times is written in the excited tone of a true believer, and I'm a heretic. The claim is that morality is hard-wired into the brain, and that experimental psychology (with its LiteBrite phrenology, the fMRI) is the window into that wiring.

The main problem I have, grosso modo, is lightly touched upon by Pinker about midway through his article where -- in the context of categorizing the moral priorities of various cultures -- he tosses off a brief disclaimer about whether a given anthropologist is a "lumper or a splitter." The implication is that, if one lumps enough, one can find a useful number of moral categories whose distribution can be predicted by presumed psychological laws.

But morality (which Pinker, if you notice, never gets around to defining) is the very art (or science, or discipline-of-thought) of making such distinctions. Recourse to broad generalities of human behavior (that millions of people around the globe tend to respond the same way to a an Internet survey about counterfactual trolley accidents) is not the same thing as discerning the sources - let alone the definition or guiding principle - of morality. That various approved opinions or behaviors are "moralized" (smoking) or "demoralized" (premarital sex) does not mean they are indicators of changing boundaries of morality, merely that high dudgeon is fungible.

Lumping and splitting is particularly tricky when it comes to religion. This is important, because comparative religionists like to lump. I don't know about the details of many religions, but when "the holy ablutions and dietary restrictions of [...] Orthodox Jews" (that 'Orthodox' drives me nuts, but never mind) is taken as an exemplar of the moral categorization "purity," I raise an eyebrow. The same mistake is made here by which Chomsky facilely lumps all languages into the same hard-wired diagram. Which "holy ablutions" are meant exactly? There are a number in the Torah, and they don't all serve the same purpose. The aim of kashrut, in the Biblical worldview, is a vexing question. I think Milgrom has it right with his proposal that the dietary restrictions are a way to separate out the Jewish people in holiness from the nations. But this is a crucial distinction and something different from "purity."

I don't deny that moral psychology is a science that will contribute to our understanding of morality. But definitions, and fine distinctions, make morality a very tangled tissue to see with any scan.

Hillary Clinton's Health Care for All

Cost Containment, Individual Mandates, and Free Choice - Too Good to be True?
[See a comparison of the Giuliani and Clinton plans at Clinical Correlations.]

Hillary Clinton's health care plan is only a few pages long, but the difference between a health care plan and a piece of legislation is the difference between a paper airplane and a space station. Let's look at some of the details of her plan and see where complications might ensue. Clinton's proposed plan would require every individual to choose an insurance plan of some kind. Anyone could keep their current insurance if they were satisfied with it. If they weren't satisfied, two choices would be available: one a menu of private options offering the same benefits as the health insurance that members of Congress are provided with, the other a public plan similar to Medicare. Tax credits would be offered to working families to make it easier for them to afford insurance. How would this be paid for? One answer of Clinton's is a traditional claim of politicians from time immemorial: savings will be achieved through eliminating waste, fraud, and abuse - but with additional savings from the use of medical informatics.

The details aren't spelled out, and those are where the complications come in. (The following discussion owes a great deal to the blog Health Care Policy and Marketplace Review.) Through the two insurance options envisioned by Clinton - a private menu offering the same benefits as those available to members of Congress, and a government-run insurance plan similar to Medicaid - the government would do two things: establish an individual mandate (i.e., requirement) for health insurance - everybody would have to purchase some - and, second, place the government in direct competition with the private sector. How this competition would be legally implemented, and which side the eventual legislation would favor, is impossible to know. Clinton also promises a reduction in premiums. This will happen only if the promised reductions in waste, and increases in efficiency, translate into greater savings for the healthcare "consumer." Neither of these are guaranteed. In particular, Clinton mentions two routes to cutting costs which are trickier than one might imagine: preventive care and information technology. Preventing, you'd think, is cheaper in the long run than treating, and electronic medical records are cheaper than paper. But neither assumption has been borne out by the literature. (A third often proposed salvation, pay for doctors' performance, or for positive outcomes, is just as difficult - but it's not among Clinton's proposals.)

I mentioned earlier one of the key provisions of Clinton's plan: an individual mandate for health insurance. This is paired with other requirements that other participants in the system must follow. To quote:

• Insurance and Drug Companies: insurance companies will end discrimination based on pre-existing conditions or expectations of illness and ensure high value for every premium dollar; while drug companies will offer fair prices and accurate information.
• Individuals: will be responsible for getting and keeping insurance in a system where insurance is affordable and accessible.
• Providers: will work collaboratively with patients and businesses to deliver high-quality, affordable care.
• Employers: will help finance the system; large employers will be expected to provide health insurance or contribute to the cost of coverage; small businesses will receive a tax credit to continue or begin to offer coverage.
• Government: will ensure that health insurance is always affordable and never a crushing burden on any family and will implement reforms to improve quality and lower cost.
  

What "fair prices," "high quality," and "large employers" are taken to mean has been a source of debate even before the first Clinton health plan. How will affordable coverage be mandated when some estimates place the cost of family health coverage at $12,000 per year? If twenty-five employees is the cutoff definition for "large business" (as the Clinton campaign has indicated), what would smaller businesses be required to provide?

The two other pillars of Clinton's proposal are making health care affordable and fiscal responsibility. Health care affordability would be made possible by tax credits for families and for small employers, and for limiting the cost of premiums as a percentage of income. Affordability in this case means - affordable for the end consumers of health care, individuals or employers. This is different from affordability for the Payer of all Payers, the federal government, and, by extension, the individual taxpayer.

What about fiscal responsibility? The Clinton plan predicts that "most savings [will] come through lowering spending due to quality and modernization." As Robert Laszewski of the Health Care Policy blog says, this could be Clinton's most dangerous assumption. If quality and modernization cannot ensure savings by themselves, (a much safer assumption), if providers and payers cannot agree on cost-limiting measures, if more taxes on the higher brackets (i.e. the rich) will not be enough to balance the books (as Clinton assumes), what will happen to the Clinton plan?

Laszewski points out that "from thirty thousand feet," all Democratic healthcare plans look the same: lots of new spending to guarantee access for all Americans to some sort of health care plan, whether public, private, or in between. Republican plans, for their part, tend to invoke individual mandates, a vibrant free market of competing health care choices, and technological efficiency. Informed consumers with the proper incentives would know to allocate their resources efficiently. (Whether Medicare Part D proves this assumption is open to question.) If Clinton's health plan stakes out a centrist position in between these two, in what direction will the "sausage factory" of legislation push the finished product? We'll see . . . if she gets that far.

Floating residents

I was talking to one of my interns the other day - she had a child in medical school, and is thinking about having another one - and she pointed out that our residency program (like many others, I imagine) has no maternity leave. Meaning: sure, you can have a child during residency, and no one will fire you for that (nothing short of killing patients will get you fired from a residency program, so desirous are hospitals of working diploma'd bodies) -- but you will have to cobble together your own leave, and it won't be any more leave than what is granted to any resident under our current schedule: namely, four weeks of vacation (two times two weeks) and several months of elective (still working, but pretty much nine-to-five).

On second thought, since employers are required to guarantee more maternity leave than that by law, I suppose our residency program is indeed guilty of failing to offer proper maternity leave. No one will take it to court for that reason, because residency programs have long enjoyed the benefits (and curses) of the twilight zone between educational establishment (students can work, and be made to work, as much as they agree to) and patient-care employer (subject to 405 regulations and all the rest of it).

If our residency program, and all others, were (made) to decide that they should offer proper maternity leave, in a block like other employers do, how would this happen in practicality? Two things would have to be true: residency programs would have to allow residents to finish in longer than the time customarily allotted to them; and "floater" residents would have to be available to fill in the gaps when others take leave. (You can't have residents in the same program fill in, as this would undoubtedly run afoul of work-hour regulations.)

Floater residents: why not? Our program hires moonlighting attendings, PAs, and all manner of other healthcare providers.

On Working With People Who Are Just Slightly Younger Than I Am

How old do you have to be before you no longer have to say "peace out" and "peeps" (="people," e.g. "patients": "Let's go down the list of your new peeps.")? Am I old enough to be exempt? I never got the e-mail.

On Having An Unasked-For Day Off Tomorrow

Thank you, Jesus, for giving our family this time together.

A Non-Profit's Molting Pains
The byuralistke speaks.

Yugntruf just changed its entire executive board and hired a new office manager. She's learning Yiddish as she starts her new job: her blog (in English) gives me some cause for optimism.

Not a haiku

I crave glass clear
to the other side, swimming
through the bottle
towards a reversed message:
HOLD WHOLE WORLDS
IN WAKING HOURS.

Semper septic

It's the damn inevitability of sepsis in the ICU which is so tragic and frustrating. It's like every patient's story has the same ending.

Long umbilical cords
and other poetical equipment.

"...room upon room of song, smell, death, and dance from the four corners and the mixed races of his family, and much else besides: from Jews to African-Americans to Poles."

More in H_NGM_N #7, and my review of Sean Thomas Dougherty's Broken Hallelujahs.

Frustrating idioms of the medical profession
First in an endless series.

"workup": tests, imaging, and the like which doctors use to analyze the cause of or prognosticate a given condition. "He had a full workup": the doctors did the tests they thought indicated. Unfortunately, when one uses "workup"without thinking, it can appear that all doctors agree what tests should be done, or that the tests are sufficient. "Had a cardiac workup" does not usually mean "exhaustively risk-stratify a patient for cardiac disease, determine its etiology, and plan for treatment," but rather "was ruled out for acute coronary syndrome [heart attack] or arrythmias."

That's first off. Second is the philosophy of medicine that "workup" implies: the body is a machine, lying there broken, and we approach with our tests to tinker until whatever broken part is repaired. Sometimes this philosophy is appropriate, but more often than not the patient is left dissatisfied after the "workup is negative."

Next up in frustrating idioms: "so we can see what's going on." ("Just get a CT scan of the abdomen so we can see what's going on.")

"Finger pads" in Spanish?
Ahora sabemos.

M. H. Graham just sent me a complimentary copy of her Ahora Hablo! Medical Edition, a handy paperback of Spanish terms useful for medical professionals.

It seems useful and relatively error-free (there's the odd typo, but no big deal). Had I seen it in a store, I would have bought it - it's only ten dollars. The most important feature of the book is that the words and phrases it includes are used nearly every day by many healthcare workers -- fun conversation starters like What color is your stool? and Do you have asthma? My Spanish is fluent (though not native) and I can testify that I've already learned a number of words from this book I didn't know before.

On the wrong side?

I realized just this year, perhaps later than everyone else, that I have been misunderstanding the entire* story in Genesis about the massacre at Shechem by Shimeon and Levi occasioned by the rape** of Dinah. I have always taken it as obvious that Shimeon and Levi did the wrong thing - that Jacob scolded them, and that their answer ("Is our sister to be treated like a harlot?") is self-righteous indignation. For the first time, I realize that the Chumash* does not disapprove of the actions of Shimeon and Levi. The reason Jacob says nothing after Shimeon and Levi's response is that he has lost the argument. The reason the Chumash does not disapprove is that God is on the side, here, of those who massacre the unclean.

*Putting aside for a moment the multi-authored nature of the Chumash, which I think is evident.
**If you think "rape" is the right translation - open to question.

The Lonesome Death of Max von Pettenkofer
From the American Journal of Epidemiology.

In the mid-19th century, the German hygienist Max von Pettenkofer viewed cholera as resulting from the interaction between a postulated cholera germ and the characteristics of soils. In order to cause cholera, the cholera germ had to become a cholera miasma, but this transformation required prolonged contact of the germ with dry and porous soils when groundwater levels were low. This hypothetical germ-environment interaction explained more observations than did contagion alone. Despite its attraction, von Pettenkofer's postulate also implied that cholera-patient quarantine or water filtration was useless to prevent and/or control cholera epidemics. The disastrous consequences of the lack of water filtration during the massive outbreak of cholera in the German town of Hamburg in 1892 tarnished von Pettenkofer's reputation and marked thereafter the course of his life. von Pettenkofer's complex mode of thinking sank into oblivion even though, in hindsight, germ-environment interactions are more appropriate than is bacteriology alone for explaining the occurrence of cholera epidemics in populations. Revisiting the fate of von Pettenkofer's theory with modern lenses can benefit today's quest for deciphering the causes of complex associations.

Trauma in the slot
Notes in and out of the ER.

Oh hell.

I put down whatever I'm doing, sometimes spilling it/surprising the patient/abandoning my computer orders uncompleted, and quick lope across the hall to the Trauma Slot (it's a room with space for several trauma victims), where I put on a disposable gown. Then I am supposed to shear off the victim's clothes and stick an IV in their arm. He (they're generally hes) is lowing, often drunk or otherwise substance-addled, but definitely in pain. I don't move fast during this ritual, nor in general, so a few minutes into the slot I'm standing uselessly at the side of the room, waiting for some signal from a superior to go get more work done inside the ER.

Back in the ER desperation on all sides: patients ask when you're going to see them, families wonder what's going on, why hasn't the X-ray been read/glass of water brought/IV taken out of arm/broken bone been set. Nurses are busy doing something else. Senior residents drift from corner to corner of the ER, occasionally assuming a stance ten feet or so away from the patient board on your end, with a look of quizzical impatience: why aren't things moving faster? Why hasn't N, with the abdominal pain, been seen yet?

Rounds punctuate. Someone is admitted - off our hands. Someone is waiting for dispo - a test, for example, to decide whether they'll stay or go. Attendings talk about patients right in front of them, in the third person.

But nevertheless (despite all these initiation rituals that I thought I left behind with intern year, but now as a second year resident I am submerged in again, on this my ER rotation) I am seeing pathologies I never laid eyes on before: the dinner-plate eyes of cocaine, the writhing appendicitis, the horrible pain of a cancer patient that knows (or doesn't yet) that it will never go away completely.

Always the crush of patients to muddle through (primary care medicine in the Bush era), always the disappointed person who hoped that their months-long back pain would be cured by a 4 am visit to the ER. And always, in the middle of all this, the cursed interruption: Trauma in the slot!

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
Again.

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.

Loneliness/Holiness
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!

Monster Library Extravaganzas
. . . and other pop-culture phenomena, through Vilna Ghetto posters.

Like life, these Vilna Ghetto posters are not inspiring at first glance. Some of them could even be called uninteresting, the sort of thing we would pass on a busy Manhattan street without a second glance. A Hanukkah party, a lecture, a basketball game. But initial glances can be deceiving. First, many of these posters are handwritten (some with calligraphic skill); second, the great majority of them are in Yiddish, and third — and most important — the posters are the uppermost, visual layer of daily life in the ghetto.

More in the Forward.

Thirteen days late
and a few shekels too short.

Why - you might wonder - do American Jews, of mostly Ashkenazi ancestry but converted in recent decades to "Sefardic"* pronunciation, mostly say "Rosh Hashanah and Yom Kippur" rather than "-shanah" and "Kippur" (or "shanah" and "Kiper")**?

I wondered that too. But I have no idea. Any takers?

*Ashkesfardic.
**I know I'm supposed to use IPA. So [su] me.
***Where is Naomi Chana, anyway? I miss her and her footnotes.

Medical epistemology
Or: why doctors and patients think so differently.

I gave a talk yesterday on this topic at NYU's primary care residency program. The outline (together with a bibliography) is here. More later if interest.

Charedipedia for real

This site makes Yiddish Wikipedia look like a bunch of porkeaters.

Yet another DNR
Do Not Reimburse.

A recent article in the New York Times publicized changes in Medicare subsidies. In the article’s own words, “Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move [that] could save lives and millions of dollars.” This change was widely discussed, no less so in our hospitals.

But the devil is in the details. What is a preventable error? How was the list modified, and whose idea was this in the first place? What are the implications for our daily practice?

Learn more in Clinical Correlations.

You say you want to understand epidemiology?
1. Be skeptical. 2. Don't believe the results. 3. Wait for a randomized clinical trial.

If those three points aren't enough, read the latest in Gary Taubes's ongoing crusade to take epi down a peg.

Gay? Okay!
Apparently uncontroversially. And uninterestingly.

I love my shul but sometimes it drives me up the wall.

For instance, a recent letter (signed by the Chair, the President, and the rabbi) informs us of some recent deliberations of our Ritual Committee, which discussed "how [the recent] decisions of the CJLS [regarding homosexuality] would affect our membership criteria; and second [. . .] whether or not we would recognize and celebrate gay and lesbian relationships." The conclusions, unsurprisingly, are that "two adult Jews who are members of the same household may enjoy a joint membership" and that "we should publicly acknowledge same sex relationships in the ways we currently acknowledge married couples. This change would mean that a gay or lesbian couple could hold a commitment ceremony in our synagogue and be called to the Torah together in celebration of an anniversary." It is also unsurprising that "both recommendations were overwhelmingly endorsed" by the shul's governing bodies.

I agree with all this! This is all good, for reasons I think I've outlined before on this blog and which scholars have defended in the relevant teshuvot: in short, homosexuality is not immoral, halachah and morality should reinforce each other despite significant but temporary contradictions; and, just as the prohibitions in the Torah have been continually re-understood throughout the generations, our generation is bound to do the same. What drives me nuts is that none of these plausible reasons - no reasons at all! - are stated in the letter. Sure, our rabbi spoke about these issues from the pulpit, but now, when actual decisions bearing on peoples' lives have been made in our shul, would be the perfect time for a full-throated (re)statement of the principles our shul finds applicable in this situation - or, at the very least, why these recommendations were "overwhelmingly endorsed." What is it about gay and lesbian commitment which put it onto our shul's agenda? Do we think not recognizing such unions is a moral wrong? Then say it! Put some bite into the "overwhelming endorsement"!

I wonder if the way this decision might have been made in our own shul (I don't really know how it was made, since I wasn't at the meetings; I'm just speculating) might reflect how it might be made in the Conservative movement at large. There are two possibilities that come to mind. One is that the majority of Conservative Jews (who care about such matters at all) have already made their own intuitive halachic decision. Puk chazei: go and see what the people are doing, and what they are doing is failing to endorse the putative immorality of homosexuality or the eternal validity of toevahschaft. Second is that people don't really care; this halachah is something which was ignored, or taken for granted to be invalid in any case.

I much prefer the first option. In that case, I would welcome (again) an endorsement by our shul's leadership, that this change was taken for positive, halachic-affirming reasons and not merely as a drift down the stream of inertia.

Year out!
A message from Shawna Tova and Felix Anyo-Nuevo.

May your new year be modified by all the adjectives you yearn for.

Eschatology ho!
Elul concentrates the mind wonderfully.

I have been reading the ninth chapter of Maimonides' Laws of Repentance, with its differentiations among the various final chapters of our worldly existence. Maybe because the world at times feels well-nigh unraveled, there's not just one end of days but multiple: the world to come (where the righteous sit, crowned by the Divine radiance), which is not the same as the Messianic age. Per Maimonides (quoting the Talmud), the Messianic age is different from the present age in one particular only: the Jews' sovereignty over the Land of Israel.

"But we're there!" you might say. Not so fast. If you are in the mood to quibble, you might say that (a) the current State of Israel is not coextensive with the Land of Israel, and/or (b) the current sovereignty is not the same as the Kingdom to which the traditional sources refer.

But I don't quibble - not because I think the current political situation in Israel can be identified with malkhus ("sovereignty"), but because I don't think that malkhus is the criterion for the messianic age. Even if there weren't multiple opinions in the Talmud about what the messianic entails, I still wouldn't think such sovereignty is important enough to serve as the hook to hang the Messiah's hat on.

Certainly sovereignty is important (I'm enough of a Zionist to say that), but we need something else to convert the world-that-is into the world-that-ought-to-be, something basic and transformative. It doesn't seem like the return of Jews to our historical homeland, as positive and uplifting (and basic) an endeavor as this is, quite fits the bill.

How then will the messianic age differ from our own? (Providing one believes in such an age.) I don't have any neat answers.; anything neat enough to propose here would be flat and unsatisfying. But I agree with a friend of mine, Richard Claman at Town and Village Synagogue, who has said more than once in his lectures that Conservative Jews have been afraid of discussing eschatology - the end of the days. We have left that stuff to the fundamentalists, at our own peril.

The point he makes is this: when we teach our children about Judaism, we brainwash them. Clearly we think that the benefit of this brainwashing outweighs the downside of coercion. What is the benefit? Do we think that our Judaism will bring redemption to the world? a dawn of peace? does the Jewish people have a unique role to play, and if so, what? What is the malkhus which our Messianic age will bring?

Death and the sleepless resident

It turns out that work-hour regulations for residents do nothing one way or the other for patient mortality. (Or almost nothing.) I'm not sure what this tells us. Were work-hour regulations really instituted on the theory that this would directly benefit patient mortality? There are other indices, I think, which are more likely affected (patient-provider relationships, morbidity, error rate), even though they are harder to study.

Take two different patients who both die in their second week of hospitalization. Patient A is cared for by well-rested residents; patient B, by zombies. I think patient A received the better care by a number of measures, even if mortality-wise they're even.

Happy holidays!
Awe! Isn't that sweet?

I like this time of year because there are so many different ways of greeting someone, and I think I variously use all of them:

Happy New Year!
Leshana tova! [Ashke-Sfard pronunciation]
Shana tova u-metuka!
Leshone tove! [American-Ashkenazic, i.e. stress on the penultimate syllable]
A gut [zis, gebentsht, . . .] yor!
Leshone toyve [tikoseyvu]!

Add your own that I've forgotten, in this blog's famously rowdy and hyperactive comments section.

Charged with punishment: the Artscroll

Marc Shapiro, the Modern Orthodox historian, has an erudite, wide-ranging, and entertaining post over at the Seforim blog (thanks to S.); the conceit here is that Shapiro is trying to find mistakes with Artscroll. Buried in the middle is a nugget which points up (to me) why even Modern Orthodoxy can be difficult to understand.

Shapiro wonders how to translate אדון עולם, i.e. the first two Hebrew words of Adon Olam: "eternal Lord" or "Lord of the world"?

[ . . .] I was pleased when I found the perfect example of an Arscroll error, and this in a prayer that we all know well, Adon Olam. What do these words mean? To answer this, most people will open their Arscroll siddur. Artscroll translates, “Master of the Universe”. This, or similar translations (e.g., Lord of the Universe, Master of the World) seem to be standard. Yet for a while I was convinced that the proper translation was “Eternal Lord.” After looking at the song as a whole, and seeing how it speaks of God’s eternity, it appeared clear to me that this is what the first two words mean.

Agreed! And refreshing (thought I) to see recognition in Orthodox circles (okay, recognition by one Orthodox writer) of a text's plain meaning.

But it was not to be. In Shapiro's words:

A few weeks ago I received a letter from R. [Meir] Mazuz[, a Sefardi scholar], and well, let’s just say that I won’t be trying to impress people any more by pointing out that Artscroll has mistranslated Adon Olam. To begin with, R. Mazuz insists that Adon Olam is identical with Ribbono shel Olam. As for my point about “olam” never meaning “world” in the Bible, he writes:

זו דעת החוקרים האחרונים שעולם בתנ"ך פירושו נצח, אבל חז"ל לא הבינו כן

As proof for this he refers to Berakhot 54b

כל חותמי ברכות שבמקדש היו אומרים: עד העולם. משקלקלו הצדוקין ואמרו אין עולם אלא אחד התקינו שיהו אומרים מן העולם ועד העולם

At the conclusion of the benedictions said in the Temple they used at first to say simply, “forever.” When the Sadducees perverted their ways and asserted that there was only one world, it was ordained that the response should be "from world to world” [i.e., two worlds].

He also called attention to a passage in Sanhedrin 58b where the verse in Ps. 89:2, עולם חסד יבנה, is understood not as “forever is mercy built,” but as “the world shall be built up by grace.”

As I said, I am forced to conclude that in this case Artscroll gets a pass.

This is very frustrating! R. Mazuz seems to believe that the interpretations of Chazal trump pshat, even when other readings are more plausible and even (in this case) when the piyyut in question is post-Biblical, not to mention post-Talmudic! It feels weird, like Shapiro is being yanked back into line by the unseen hand of Orthodoxy.

Meaningless directions

If you have occasion to compose or think about your living will (and I hope you will soon), please do not include the phrase "heroic measures," which means nothing at all - or, rather, many different things to different people. One person's heroism is another's medical routine. If you would rather not be resuscitated (i.e. have your chest forcibly compressed and undergo electric shock), then say so. If you would rather not have a tube down your throat to aid in breathing, say that. If you would rather people not do "too much," decide what that means to you, and write that down - and tell the person you would like to make health care decisions for you if you cannot. Don't count on people understanding what you write unless you are painfully detailed and inescapably clear.

Presenting the second-year resident
Now in a magically supervisory capacity.

Said the cattle thief: it's time to take stock.

The intern is a snake devouring its own tail. The second-year resident ("R2" is the quasi-robotic nickname) is still chewing at her tail but is also keeping an eye on the tail-devouring of other snakes, with helpful comments all the while. "Open the maw a little wider! Fangs into the tail like you mean it!" And the hot sand all around, with the Georgia O'Keefe-ish carcasses. And the whistling of passing trains.

The meaning of the allegory: I still sometimes don't feel like I know what I'm doing, even with years and years - I mean, fourteen months - of medical experience under my belt. I know for a fact, more abstract than concrete and more intuitive than learned, that it is better to say "I don't know" than to invent a probably-misleading principle on the basis of limited information. But the latter is what I see people doing all the time around me, and whenever I say "I don't know," I still feel guilty and weak.

Some of this is due to lack of confidence, which will be repleted steadily until my graduation, at the end of my third year of residency. Some of this is due to epistemological uncertainty. I don't know what it means to know about medicine, and at times I'm not sure that everyone else does either.

Let me qualify: there are many models of what it means for a doctor to know something, but none of them covers all the situations that we encounter. "Evidence-based medicine" (one model) is a misnomer, because the "evidence" is population based, while much medicine is done person by person. There are many other jerry-rigged epistemologies, lizards skittering up and down the hospital hallways between the feet of housestaff. "See one, do one, teach one" - sure, but what is "seen" and "done" depend very much on how one is taught. Diagnostics is an epistemological minefield: take into account all your probabilities (Bayesian and otherwise), but you must still walk into a patient's room with at least two or three layers of information and attempted diagnoses made by other people in the hospital who have seen the patient first. Seasoned diagnosticians often cannot explain how they arrive at the correct diagnosis; on the other hand, autopsies (of a previous generation; these days they're rarely done) indicate that diagnoses are wrong about a quarter of the time.

The epistemologic dissonance par excellence is between doctor and patient. The doctor knows the patient's sick, and the patient doesn't believe this at all - or vice versa. The patient knows what's going on in her body, but the doctor needs to do another test to find out - because he says he doesn't know yet. You can say that this is because doctor and patient subscribe to different epistemologies (biomedical vs. traditional, quantitative vs. narrative, or what-have-you), or you can say that neither doctor or patient knows how they know things, or thinks about it much at all. (Meta-epistemology? You came to the right place.)

Now I'm a second-year resident, with more time to think about how I (don't) know what I (don't) know. This is precisely the time when I am supposed to start conveying my knowledge to those one step below me: the interns. (Many of whom, in terms of raw medical facts and figures, know more than I do anyway.) It's appropriate that I don't feel like I know how to do this.

Perhaps I'm thinking about this all wrong. Medicine (or, to term it more appropriately, health/sickness/wellbeing) is based not on knowledge but faith. Induction is a leap. The sun will rise tomorrow because we've seen it done so for our entire lives and heard stories about its constancy. Doctors and patients alike put themselves in the hands of their combined trust: standing at the foot of the mountain or at the door of the hospital.

Yiddish Week 2007
Reflections, 1.

I'm back from the Yiddish Week. The strangest thing is how normal we all are, we fringe Yiddishists, all the flavors of (mostly American) Jewry represented: the usual Reconservadox spread plus a Charedi couple; secular folks; old and young; couples with jelly-smeared kids. And it feels like (maybe?) that there are slightly more people with kids and 2o-somethings among us. On the one hand, speaking Yiddish should be normal for those American Jews that do so. It should be a choice on the menu with the respect due it - by no means the only one, but definitely a possibility. On the other hand, ideologies that seem normal are tame. We don't want to be stamp collectors, do we?

You look so drawn

Satisfactory Comics has a blog!

Fuftsik Sent and Madona
Yiddish rap in the Jewish state.

Check out this article in Yediot Acharonot. I haven't heard the sound files yet. (Thanks to reader MJ for pointing this out.)

Update: As usual, I'm about three to four months behind the curve -- the disk came out in May. I just listened to some clips. Lipa it isn't, just saccharine frumification of perfectly good music. (Why would you need an ultra-O version [track 5] of La Isla Bonita?)

(Speaking of Yiddish and Madonna, the new issue of Afn Shvel has a great article by Marc Caplan on Ms. Ciccone Ritchie and her practice of Kabbalah.)

Incrementalism versus single-payer health care reform
Different routes to the same solution.

Cross-posted to Clinical Correlations (with some edits there)

Health insurance positions: The obvious imperfections of our current health care system have inspired a number of solutions. They can be organized into two broad categories, incremental or single-payer. Each of these solutions is advocated by a single-issue lobbying group. National medical organizations support these solutions in greater or lesser measure.

Advocacy groups: Physicians for a National Health Program provides information about the benefits and practical implications of a single-payer health care system. The list of members of its advisory board includes their organizational affiliations, but (as its name indicates) the group is composed of physicians, not medical organizations or professional societies.

Incrementalism is represented by the National Coalition for Covering the Uninsured, a broad-based coalition of a number of organizations, including the AMA, the American Hospital Association, the American Public Health Association, the American Academy of Family Physicians, pharmaceutical companies, insurance companies and other organizations. Given the divergent range of interests and philosophies represented by this list, it's no surprise that the NCCU's plan involves a number of less wide-reaching improvements in the current system, including transparent pricing; personal Medical Savings Accounts; and the expansion of public programs to cover the very poor.

Professional organizations: Many medical organizations act as both professional societies and as advocacy (i.e. lobbying) groups. Their "home" positions may in many cases differ from their compromise positions hammered out in coalitions with others. The American College of Physicians, on its Web site, advertises its support for the Health CARE Act, a proposal which would increase federal matching funds to those states expanding Medicaid coverage to all those beneath the federal poverty level, and which would also provide increase federal funding to those states which increase coverage for uninsured children.

For its part, the American Medical Association "will strongly advocate for incremental measures to expand coverage," and in keeping with this advocacy is a member of the HCCU. In the long term, says its Web site, it will continue to push for the adoption of a market-based plan to expand coverage, "relying upon incentives and voluntary approaches." Similarly, the American College of Surgeons endorses universal access to care "within our current pluralistic health care system," i.e. to be incremental in the pursuit of change, with some features being implemented on a state by state basis. The ACS further emphasizes that "reducing health care costs [through improving information technology] is much more desirable than containing costs by rationing care."

Compared to other professional organizations, the American Academy of Family Physicians is full-throated in its advocacy of a plan to ensure health care coverage for all. On its web site, it lists those services which should be covered for all who reside in the United States (a relevant distinction in these days of proposed immigration reform). Assured services with no co-payment include prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; and evidence-based periodic evaluation and screening services. Other assured services, including outpatient physician services and outpatient prescription medications, would require 20% co-payment. The AAFP is also the rare organization which specifies a funding mechanism: a national, broad-based tax. Under the AAFP plan, coverage would be rationed by a "resource-based relative value system."

Differences and similarities: The differences in advocacy positions - taken on their own and as participants in coalitions - of the American professional medical organizations remind practicing physicians, and especially physicians in training, that the current health-care system can justify various solutions. Advocacy can also be modified in coalition for the sake of practical lobbying.

Personally, I think a single-payer system is the only solution that would fix the gaping inequities in our system -- but I also realize that there are many ways of getting there. PNHP might better fit idealists, and NCCU, realists, but they have a goal in common: reducing the numbers of the uninsured. Perhaps the coalitions can themselves coalition to put the problem of the uninsured higher on the agenda of the 2008 elections.

Mr. Hales and his medical husbandry

"The first person to measure blood pressure was Stephen Hales, an English clergyman of creative genius, who in 1708 directly connected the left crural artery of a horse to a 9-foot-tall glass manometer using brass tubes and a trachea of [a] goose." (from McGee, Evidence Based Physical Diagnosis)

Our Son Leaves His Fifty-Inch Plasma-Screen TV
Behind Because There Will Be
No Room in the Dorm

The remote control is eight inches long
with a display that I never understand
no matter how many times
you explain it: "Dad,"
you said, looking not at me
but the flitting basketball
and the neon cheerleaders,
"it's universal." So it
is. Then why is it only your Mom and me
who have to stare
at this blank Buddha
in our living room?
Its four sides
four years
times forty
thousand
dollars.

The narrative voice is bliss

At times the Gemara gets so intoxicated with its own line of thought that it just goes right ahead and ignores the Mishnah.

(d)(5) hold on a minute!
In this week's New England Journal of Medicine, Wendy Parmet provides legal justification for my inchoate worries. (More about the author.)

Many important questions remain [regarding quarantine and detention for tuberculosis control]. First, courts have not decided how long someone may be held before a hearing is offered or what procedures are necessary in the event of a mass quarantine. Courts have also not yet decided what probability of risk justifies short-term or long-term detention. Nor have they clarified what evidence is needed to determine that a person is or may be infectious or how infectious a person must be to justify isolation. Most critical, courts have not explained what must be shown to conclude that a patient is noncompliant so that detention is the least restrictive alternative. In tuberculosis cases, courts have upheld detention when a patient has failed, like [Andrew] Speaker, to follow medical advice. But they have not considered how forcefully that advice must be given or what, if anything, the government has to do to facilitate compliance. [. . .]

Compulsory isolation and quarantine alone cannot stop the spread of XDR tuberculosis. Moreover, excessive reliance on compulsory measures can lull the public into a false sense of security and at the same time prompt people who are at risk to do exactly what Speaker did — run. Fortunately, most persons infected with tuberculosis want treatment and have no desire to infect others. When clinicians and health officials work with patients and have their trust, most will cooperate. By ensuring that coercion is used only when less restrictive alternatives will not work and with due regard for the rights of those detained, the law can foster public trust, minimizing the need for compulsion and laying the groundwork for the comprehensive and costly control programs needed to prevent the spread of XDR tuberculosis and other contagious pathogens.

Dr. Zauberberg
Or: How I learned to stop worrying and believe in the (d)(5) hold.

I'm now rotating. (Of course, we're all rotating together, being on the Earth and all.) I'm currently working on the Chest Service of Bellevue Hospital. "Chest" means "lung" which means (at least for most of our patients) tuberculosis. There are lots of lung diseases, but the most common ones (pneumonia, asthma, COPD [emphysema and bronchitis]) get thrown in the same big barrel as all the other medical conditions, spread out among all the other medicine teams on the regular wards. This particular ward I'm on now is limited to the tubercular.

It is a Manhattan version of the Magic Mountain. There are New Yorkers of unexotic ethnicity (Puerto Rican, say) who have AIDS; there are Asian immigrants who have had the misfortune to contract drug-resistant TB; there are the elderly and demented from Coler-Goldwater, who are exiled from their residence until their cultures come back negative, no acid-fast bacilli swimming redly past the eyepiece.

And then there are those who are under arrest, under Article 11.47(d)(5) of the New York City Health Code. In other words: they have TB, and they can't or won't either take their medications or modify their behavior so as not to pose a risk of contagion; they have been warned, and now they are shut in. They are under (d)(5) hold.

This is justified by public health necessity, which is defined by the New York City Department of Health. On a case by case basis, the DOH balances the danger of contagion, the necessity of treatment, and the contingency of private circumstances.

I wish I had something wise to say here, something which would precisely trace this intersection so we could see it as clearly as pathologists see the offending acid-stained bacilli. All I can do - as usual - is ask myself questions while I immerse myself in the work the system requires of me in the name of the patients.

I've been thinking all day of the word "misprision," but I'm sure it's not as foreboding or relevant here as it seems.