America's Next Top Health Policy Problem

James Knickman, the unassuming and friendly health-policy analyst and CEO of the New York State Health Foundation, talked to our class of third-year primary care residents on Tuesday as part of our health policy course. Here is his list of the Top Ten Health Policy Crises.*

Solutions received by Monday at 7pm will get a free piece of apple-and-honey.

1.The lack of affordable and accessible health care for all Americans.

2. The need to develop methods to decide when to pay for emerging modalities and pharmaceuticals.

3. The need to move resources into prevention and public health.

4. The need to move resources into primary care.

5. How do we care for an aging population?

6. How do we expand physicians' use of evidence-based treatment approaches?

7. Great disparities across ethnic and income groups.

8. Malpractice!

9. Dental care.

10. The lack of health-care professionals.

*Okay, he didn't say "crises," he said "topics." But "crises" is more fun.

"Diagnosis of exclusion"

A zillion years of medical and graduate school, and nearly three years of residency, and I still don't understand what it means when people say that such-and-such is a diagnosis of exclusion. Any diagnosis is a diagnosis of exclusion!

Often, I think, people use that phrase as a retelling of the widespread myth that psychopathologies can't be diagnosed through testing. ("Anxiety is a diagnosis of exclusion.") Or a claim that only laboratory tests or imaging matter, not the history or physical. ("Hepatorenal syndrome is a diagnosis of exclusion.")

The next time someone calls a diagnosis a D of E, by gum, I'm going to ask them just what they mean.

Jewels of Elul CXVIII: A Month of Dreamers that Feels like a Year

with apologies to Craig 'N Co.

Since I have a lot of money, people are always sending me their crazy ideas. And I have to take them home on the train. I fall asleep and dream . . . dream of long vacations, plush terry-cloth robes, little bars of soap you always steal and then feel obscurely guilty about (unless you steal from the minibar, in which case you dream about credit-card bills in the mail and some meaty guy stomping through your front door with a large stick). When I wake up from my dream, I'm at the last station stop and the janitor has to sweep me out of the car with his broom. I wander outside and can't find the bus stop. Scared, I take a taxi.

That's my dream. To some people, it's trivial, stupid, a little cheap. But then I give them some money, and the word "cheap" is never mentioned again. The word "dream" is thrown around a lot, mostly by me. The prophets of Israel, I read, used to dream. Their dreams are full of sprouting sticks, rattling bones with ill-fitting skin heaving themselves reluctantly to their resurrected feet, women eating their newborns. Not Elul stuff at all.

When I think how far I have come, and how much money I have, I thank whatever gods may be for my dreams. I might write them down in a book someday. Dreams do come true!

Well that's all right then

Worried whether your favorite presidential candidate will defeat the other party's lying traitorous scum and save our nation this November? If you care about health policy, don't worry about it. Neither man's plan has a pig's chance at a barbecue of getting anywhere near passage.

Welcome to the hekhsher tzedek community, Orthodox Union!

Or: happy Elul!

So when will the OU withdraw certification entirely from Rubashkin's? When the case goes to court? When a conviction is handed down? When the sentence is served? How many "weeks" will this take? 1? 2? 6? 12? 52?

And why does there need to be a change in management? After all, these are just goyish legal structures we're talking about (ערכאות של גוים). "The law of the land is the law" is just Conservative liberal halachah, right?

Maybe there needs to be another trip to Iowa, company-paid. Make sure one of the rabbis involved "knows some Spanish." Look, the cafeteria is awful clean!

The Art of the Improbable

Today I voted for Paul Newell and Daniel Squadron. Nothing like casting your lot with the losing team! (And speaking of losing...)

* * *

You know what's useful? Reading political news.

Fresh fish for sale!

From there to here
From here to there
New Yiddish fish are everywhere!

Now available:
Eyn Fish Tsvey Fish Royter Fish Bloyer Fish
One Fish Two Fish Red Fish Blue Fish by Dr. Seuss
Yiddish translation by Sholem Berger
978-0-9726939-3-6
$15 + shipping (and tax in NY State)
yiddishcat.com

Don't forget:
Di Kats der Payats, The Cat in the Hat by Dr. Seuss, in Yiddish--$15
George der Naygeriker, Curious George by H. A. Rey, in Yiddish--$18
Colorful alef-beys poster by Stephen Cohen--$12

The futile slow code

I was involved in a slow code recently. (I won't say where, or when, or with whom.) They are slippery and repugnant. Rarely can any of the parties involved say with satisfaction or complete clarity when, or by whom, the slow code was suggested or agreed to. It is a substitute for an honest discussion of options with the patient and family, and it is a legal minefield.

Remind me not to get involved in them again ... when I have a choice in the matter.

The Politics of Kashrut: Kosher Food Boycotts then and now

An event at Town and Village Synagogue. No word yet whether the refreshments will be fleischig.

Join JFREJ, the AJWS-AVODAH Partnership, and Uri L'Tzedek for a salon-style, interactive program: learn about the complex intersections of immigrant rights, labor rights, and Jewish law - from the Lower East Side's kosher meat boycott of 1903 to the AgriProcessors boycott of 2008.

Featuring Professor Hasia Diner, NYU, and Organizers from the United Food and Commercial Workers Union, Uri L'Tzedek, and Hekhsher Tzedek. Presented through Jews for Racial and Economic Justice (JFREJ) and American Jewish World Service and AVODAH: The Jewish Service Corps.

This event is co-sponsored by Hazon, the Workmen's Circle / Arbeter Ring, and Jewish Labor Committee/United Hebrew Trades. For more information or to RSVP click here or call 212-647-8966 ext 10.

Without any negation

We confirm the amazing achievements of Yiddish without any negation at all of the importance of Modern Hebrew, Ladino, Zionism, secular Judaism, Jewish culture as a whole (yiddishkeit) or any other intimate, creative, and authentic Jewish entity and conviction. In addition, we are not all just Yiddishists, of the sort who are committed to Yiddish and only to Yiddish. Just the opposite. We are of various Jewish ideologies. "Whatever we are, we speak Yiddish" - Yiddish is our common property and an integral part of our anchoredness in a part of our identity, our past, and in a part of our future.

--Joshua Fishman, from אַ באַגריסונג־וואָרט לכּבֿוד דעם 100סטן יובֿל פֿון דער טשערנאָוויצער שפּראַך־קאָנפֿערענץ an article in the Yiddish Forward commemorating the 100th anniversary of the Yiddish Language Conference. Translation mine.

Dance of the Dripping-Hand Fairies

I'm no choreographer, but it is important to be meaningful in the movements you adopt in front of the motion-detector paper-towel dispenser. I do want this paper towel! I do! Look, here I am reaching my arms underneath it!

Yiddish is still a national language of Jews

Happy 100th anniversary of the Tshernovits conference!

Studying with Big Pharma

The American Board of Internal Medicine ratifies a core of medical knowledge in which the qualified internist is supposed to demonstrate proficiency. I am using MKSAP to study - it's a series of study guides produced by the American College of Physicians. Before the table of contents, the contributors are listed, together with their disclosed involvement with (meaning: compensation by) pharmaceutical companies.

It'd be asking too much to eliminate pharm-phunded contributors from ostensibly nonpartisan guides which reflect the best available consensus of our profession (that would be...legitimate!). Nor do I think it's likely that their contributions will be vetted by a pharm-free referee (that would be...adequate!). In the absence of these strategies, it would be nice - paradoxically - if those medications mentioned in the text could be listed on first appearance by brand name and manufacturer. Otherwise how are we to know which contributor is putting a golden shine on the clinical evidence?

Day and night

Day and night -
We wait frozen in angry day
for night with its moon,
for moon's tenderness.

We wait terrified in angry night
for day with its sun,
for sun's clemency.

Day and night -
They think we're big,
they make free use of us.

We're small, quite small -
fear pulls us to the ground,
as if we're his, as if he owns us.

So small, what should we
do with ourselves?
Our pain, what should we do
with our pain?
Love?
Secrets?

Day and night -
They think we're big,
they make free use of us.

--Leib Kvitko (Oct. 15, 1890-August 12, 1952)
(my translation; original here)

Poets' homework

Write a poem using only these words.

It should be a good poem.

Work-hour anecdotes battle it out head to head!

Sandeep Jauhar, writing in Slate, has an introduction to the controversy around work-hour regulation for medical residents. 

1. One assumption made by opponents of work-hour regulations is that these regulations are only justified if there is a proven connection between longer work hours and more medical errors. But why is the burden of proof on those who want to change the established order? Why must we assume that the more hours doctors work, the better? Do we know that 120-hour work weeks make better doctors than 80-hour weeks, or do older doctors - who tend to be most vocal in their opposition to work-hour regulations - merely harbor nostalgia for their training days?

Would another helping profession expect its practitioners to work more hours (consecutive or total) as proof of their seriousness? Yes there is overlap between quantity and quality, but anyone who's spent time in a residency knows that an extra hour does not necessarily mean an extra hour of learning or patient care. Sometimes - often - it means an extra hour of drawing blood, doing paperwork, transporting, finding a working EKG machine . . .

2. Jahuar writes:

Work limits have troubling consequences [...] including interruption of
resident learning, fracturing of traditional hospital teams, and the creation of
a kind of shift-work clock-watching mentality among young doctors.

Notice how none of these consequences are referenced to the literature, and in fact each of them could argue, properly understood, for work-hour regulations.

For example, resident learning is "uninterrupted" by fatigue (or lack of concentration) when proper balance between work and other parts of life is ensured.

"Fracturing of traditional hospital teams": I suppose Jahuar is referring here to night-float interns or residents, people who don't work in teams. Or to "orphan" interns, coming in on the weekends when the rest of their team is off, so that someone can be around to admit patients. But how "traditional" is the intern-resident arrangement really? It can't be older (at least in the U.S.) than the teaching hospital, which itself isn't older than a hundred years or so. "Tradition" in medicine changes every few decades anyway - why shouldn't it change now?

"A clock-watching mentality among young doctors" links to a sidebar referencing not a study or review but . . . a conversation the author appears to have had with some young doctors who don't like work-hour regulations. But my colleagues - conscientious, hard-working, caring doctors - like and accept these regulations as a rule. They "watch the clock" only in the sense that every shift worker respects their own commitments whether at work or outside. Martyrdom is not our measure of compassionate, effective care or of professional devotion.

Summer song

Grass under halogen

draped by noonish shadows.

I stroll like a lazy football player

without a ball.

This all happens at summer

when boats cut open oceans.

Hating sweat

I'm waiting for winter.

The Nightfloater's Prayer

Mincha with tallis and tefillin.

A systematic review of the effectiveness of prayer for the sick

[click the post title for the full abstract]
Intercessory prayer for the alleviation of ill health.
Roberts L, Ahmed I, Hall S.
Hertford College, Cattle Street, Oxford, UK, OX1 3BW. leannerobert_uk at yahoo dot co dot uk
Cochrane Systematic Reviews 2007.

BACKGROUND: Prayer is an ancient and widely used intervention for alleviating illness and promoting good health. Whilst the outcomes of trials of prayer cannot be interpreted as 'proof/disproof' of God's response to those praying, there may be an effect of prayer not dependent on divine intervention. This may be quantifiable; which makes this investigation of a widely used health care intervention both possible and important.

OBJECTIVES: To review the effectiveness of intercessory prayer as an additional intervention for those with health problems already receiving standard medical care.

SEARCH STRATEGY: We systematically searched ten databases (June 2005).

SELECTION CRITERIA: We included any randomised trial of personal, focused, committed and organised intercessory prayer with those interceding holding some belief that they are praying to a God. This prayer should be offered on behalf of anyone with health problems.

DATA COLLECTION AND ANALYSIS: We extracted data independently and analysed on an intention to treat basis calculating, for binary data, the fixed effect relative risk (RR), their 95% confidence intervals (CI), and the number needed to treat or harm (NNT or NNH).

MAIN RESULTS: Ten studies are now included (n=7646). We found a slight difference between groups, favouring prayer for death (6 RCTs, N=6782, RR 0.88 CI 0.80 to 0.97, NNT 42 CI 25 to 167, I(2 )83%) but no differences between groups for clinical state, complications or leaving the study early. Individual studies did find some effects. One trial separated death data into 'high' and 'low' risk and found prayer had a positive effect on those at 'high' risk of death (1 RCT, N=445, RR 0.3 CI 0.2 to 0.46, NNT 8 CI 7 to 11). A second study found a positive effect of prayer on women undergoing IVF treatment with significantly more successful implantations in the prayer group compared with standard care (1 RCT, n=169, RR 0.68 CI 0.53 to 0.86, NNT 5 CI 3 to 10). A larger study assessed the effect of awareness of prayer and found those aware of receiving prayer had significantly more post operative complications than those not receiving prayer (1 RCT, n=1198, RR 1.15 CI 1.04 to 1.28, NNH 14 CI 8 to 50) and those uncertain if they were receiving prayer (1 RCT, n=1205, RR 1.12 CI 1.01 to 1.24, NNH 17 CI 9 to 201)

AUTHORS' CONCLUSIONS: It is not sensible to interpret any of the interesting results with great confidence. However, for women hoping for successful IVF treatment there are some data suggesting a favourable outcome of prayer but these data are derived from only one of the smaller trials. On the other hand, one of the larger studies suggests that those undergoing operations may not wish to know of the prayer that is being offered on their behalf. Most data are equivocal. The evidence presented so far is interesting enough to justify further study into the human aspects of the effects of prayer. However it is impossible to prove or disprove in trials any supposed benefit that derives from God's response to prayer.

The piano (a poem by Yonia Fain)

My neighbor, the famous pianist,
has gotten ever sicker the past two years,
his body has slowly shrunk
as if he were hiding himself from the world
and somewhere, with trembling hands,
holding onto a concealed
center of life.

And then one day
he entrusted me
with his apartment keys.
He had to go into the hospital
for an operation
and he asked me
to take care of his two vases
in the window.

"I can bring them to my place,"
I offered.

"No, no," he stammered.
"The piano has to live with somebody."
He hung his head
and added as if embarrassed,
"If you have time, it would be good
if once a week, in the evening,
you could just sit for a moment
by the piano."

(from Der Finfter Zman, CYCO Farlag, 2008. Original Yiddish here. Translation mine.)

Kay Ryan, poet laureate

In honor of the poet laureate being someone whose books I actually own, a selection. A short selection - the shortest possible. One poem.

Great Thoughts

Great thoughts
do not nourish
small thoughts
as parents do children.

Like the eucalyptus,
they make the soil
beneath them barren.

Standing in a
grove of them
is hideous.

(from Say Uncle, Grove Press, 2000)

More health care is not better

What explains the large variation in health care costs across the country? You would expect that the regions with the highest health care expenditures have the sickest patients, or have the highest prevalence of chronic health conditions.

But you would be wrong. Health care expenditures are highest where health care supply is the highest. As the number of hospital beds, doctors, and medical technologies (”supply-limited health care”) increases, the use of these goods increases as well.

More in Clinical Correlations, the blog of NYU Internal Medicine.

Why People Become Cannibals

There's cameraderie.

There's shared values.

They practice what they preach.

And there's always someone to have for Shabbos lunch.

[thanks to House of Gil for laying out the principles]

Best medical quote ever

“It’s incumbent on the community to dispense with the need for evidence-based medicine,” [some cardiologist] said [in the New York Times, in support of expensive, unproven "CT angiograms"].

Couples Therapy

I never lend a hand
when I can take yours
to drag our couple
across unders and overs.

What brought us together
is chicken-or-egg.
You bring and I give.
We cry and we beg.

My hobby

(with apologies to xkcd)

Judging articles in the medical literature based on whether the authors have cool names.

Boring paper:

Project LIFE-Learning to Improve Fitness and Function in Elders: Methods, design, and baseline characteristics of randomized trial.

Morey MC, Peterson MJ, Pieper CF, Sloane R, Crowley GM, Cowper P, McConnell E, Bosworth H, Ekelund C, Pearson M, Howard T.

Good paper:

Enck P, Zimmermann K, Menke G, Müller-Lissner S, Martens U, Klosterhalfen S.

A mixture of Escherichia coli (DSM 17252) and Enterococcus faecalis (DSM 16440) for treatment of the irritable bowel syndrome - A randomized controlled trial with primary care physicians.

Excellent paper:

Adeoye AO, Omotoye OJ.

Eye disease in Wesley Guild Hospital, Ilesa, Nigeria.

Afr J Med Med Sci. 2007 Dec;36(4):377-80.

Note that the Dutch are usually at the top of the heap as well. How can anyone resist these authors?

Thyroid hormone transport and metabolism by OATP1C1 and consequences of genetic variation.
van der Deure WM, Hansen PS, Peeters RP, Kyvik KO, Friesema EC, Hegedus L, Visser TJ.

Passion with a purpose

I don't read a book
One moment after it stops exciting my
Curiosity or interest, and this passion
Has finally stopped my reading altogether [...]

-David Shapiro, Poems from Deal, 1969
(thanks to AS)

Today's Strand haul

This is a blogpost, so motivated by a blend of two complementary impulses: preening (look at the books I'm reading! aren't I erudite!) and the search for people to share the books with (talk to me about them! what do you think?).

I did get some nice stuff today, and I hope the upshot here will tend more towards the second motivation than the first:

גימטריקון (Gimatrikon), i.e. a gematria dictionary
Rats, Lice, and History
How We Die
The Poems of Gerard Manley Hopkins
The Courtier and the Heretic: Leibniz, Spinoza, and the Fate of God in the Modern World
The Examined Life: Philosophical Meditations

Growth Song

Children are drinking from lukewarm brass gargoyles.
The wheel gruntingly swivels.
I stand in the field directing sprouts
mediating growth from sand to sun.
Let me be a mother-man.

Simply not honored? The "hypersensitivities" of Jewish women

Often the most interesting part of a responsum, especially a traditional responsum redolent with the assumptions of strict construction (one merely has to read the law correctly out of the proper book, and all will be truth), is not so much what is termed the "halachic analysis" (quoting sources, lists of poskim) but the interstices of the argument, in which the strict-construction myth is exploded despite itself: opinions do matter in the interpretation and creation of halachah, and in many a halachic analysis the posek's personal notions are determinative.

Consider the newly posted review (at the Seforim blog) by Rabbi Aryeh Frimer of Rabbi Daniel Sperber's Darka shel Halakha. The majority of his explicit argument is (a) Sperber misunderstands the original Talmudic statement about women and aliyot; (b) Sperber misconstrues the scope of kavod-haberiyot - it can only temporarily nullify a rabbinic decree; and (c) Sperber misapplies kavod-haberiyot to the matter of women reading Torah.

Two side comments, however, throw as much light on Frimer's argument as do the more bibliographic portions:

[I]n the case of aliyyot, no act of shame has been performed to all
those not called to the Torah (both men and women); they are simply not honored.

This is incorrect. As R. Frimer surely knows, reading from the Torah at fixed times is one of the basic requirements which a Jewish community must fulfill (not, as far as I am aware, an individual requirement, as he seems to assume). In the case of a man, not being called for an aliyah at one occasion means "simply" that he must wait for another occasion. But the possibility remains that he may someday be called. For an Orthodox woman, she will never be honored. Thus "both men and women" is a misleading formulation, and "simply not honored" is rhetorical sleight-of-hand: if one can never be honored - never participate in a basic community ritual - I think shame is something to be careful of.

The second group of misstatements is more revealing.

This view [of many rabbis] explicitly rejects subjective standards - in which what is embarrassing results from the idiosyncrasies or hypersensitivities of an individual or small group. The vast majority of religiously committed women are not offended when they do not receive an aliyya. Indeed, they understand and accept the halakhic given, although some might clearly have preferred it to be otherwise.

"Idiosyncrasies" and "hypersensitivities" are strange terms to be applied to the spiritual strivings of half of all Jews - to which Frimer begins his essay with an avowal of respect.

And then - how does R. Frimer know that "the vast majority of religiously committed women are not offended when they do not receive an aliyya"? Has he talked to them? Or are "religiously committed women" defined as those who do not think about receiving aliyot? In any case, the formulation "...when they do not receive an aliyya" is again misleading, implying as it does that we are considering an individual aliyah, one of many, which Leah or Sarah happens not to be called for at a particular moment. Rather, as I pointed out, we are talking here about the wholesale exclusion of a very large group (half of all Jews!) from a basic community obligation.

Finally:

More importantly, does it make halakhic sense that if a group of women – nay, any group, says: “this Rabbinic halakha offends me” – be it mehitsa, tsni’ut, kashrut, stam yeynam, many aspects of taharat ha-mishpahah, who counts for a minyan, and who can serve as a hazzan - then we should have a carte blanche to go about abrogating it. Such a position is untenable, if not unthinkable.

More rhetorical sleight-of-hand! The premise in this paragraph is not being advocated by any party to this dispute (or indeed any observant Jewish feminist!). I very much doubt that R. Sperber is indicating that any group which thinks itself offended by a given Rabbinic edict "should have a carte blanche to go about abrogating it" (whatever that means). It is true that when a Rabbinic edict does lead to the wholesale exclusion of women, the circumstances of the legislation (whether or not they apply, and when) should be very carefully examined. No slippery slope here, merely R. Sperber's derekh-haTorah.

To reframe the question R. Frimer is asking (but without the stacked deck): does it make halachic sense that a community which values the spiritual striving of women should consider whether its own honor is sensitive to their wholesale exclusion? The question answers itself.

Should we specialize medical education?

It's common wisdom that surgeries are better done at high-volume centers. Specialists should do what they're best at - this reduces errors.

By analogy, medical schools should do what they're best at. Different medical schools are (I speculate) better at educating different types of doctors: NYU might be better at training primary care physicians, while Columbia (to pluck a name out of the air) might be better at training future cardiologists.

So why can't medical schools specialize? Why not telescope the long and tiresome haul of medical school-residency-fellowship into a single training program?

We know "physician" is a variegated profession. Why must all doctors be trained the same? Wouldn't it make sense for a medical school to be able to choose an area of specialty, rather than trying (fruitlessly) to be all things to all possible future doctors?

The Yiddish Leprechaun of Baltimore

Presenting the genial, silver-tongued, exaggeration-prone professor (and friend of mine), Marc Caplan. His life story is worth reading about.

(He was a guest on this very blog some time ago.)

Chasidim complain about Maimonides?

Last week's issue of Zeitshrift, a Yiddish magazine from Monsey, has this cover headline in red and black:

The Truth About Maimonides Medical Center
Community leaders and dozens of former patients complain to Zeitshrift about negative treatment in the Borough Park hospital - Some leaders say that other hospitals aren't any better - What can we do to improve the situation?

Inside is a 15 (!)-page article about the hospital, its detractors, and its defenders.

GG is for pluggable

Are you looking for kids' books which are witty but not saccharine? Look no further than AA is for Aardvark, the latest creation from the unjustly unfamous Mark Shulman (a friend of mine), brimming (both author and book) with wordplay, illustrations, and double letters.

Saving a life - according to the doctors. II

If a non-rabbi could decide what sofek pikuach nefesh means, could a doctor do it? I'm not sure, because I don't think the work of a doctor has much to do with calculating mortalities - that is more fittingly the work of an actuary or an epidemiologist. If you ask a doctor, given a certain presentation of symptoms, what is the chance that a certain patient sitting (or lying) in front of them will die, they will generally say, "It depends on the patient." Doctors are notoriously reluctant to give probabilities.

Even if doctors are reluctant to quote such possibilities, maybe they still practice according to them? The literature on medical decision-making gets broader every day, and I fear to tread where I am ignorant. I know enough though to say that it strongly depends on the specialty. Sometimes subspecialties of medicine differ so much from each other it's as if they are different professions altogether. The emergency-room doctor and the critical-care physician deal in life and death every day, while the outpatient practitioner has influence in the gradual development of healing or disease - these are broad generalizations, of course.

Not blinded in Belarus

When this study on breastfeeding and IQ was hyped in the press (MSNBC; see WebMD for a better take) why did no one mention that the pediatricians who rated the IQ of the children in question (more vs. less breastfeeding) were not blinded to which group the children were in?

I would understand if the findings of the study were a slam dunk, but they aren't: verbal IQ was the only category with a statistically significant difference (performance and total were not statistically significant), and the IQ difference is probably not behaviorally significant in any case (what's five or seven points?).

Given that the differences are small and possibly not statistically significant, it behooves those reporting the news to give a sense of potential sources of bias: factors which could skew the results in one way or another. And one way in which results can be skewed is for raters to "know" or "guess" while rating the children in one group that their IQ should be higher. We are all inherently biased creatures - blinding is the way, in modern epidemiology, to reduce bias. When small results are claimed (as they are here) a source of bias like this is quite worrisome.

The cognitive benefits of breastfeeding remain unproven.

(Of course my son is being breastfed - with formula too. But the reason he'll grow up smart, God willing, is because his mother is smart.)

Grass-roots beef

Not surprising: the organizational impetus and scholarship behind the growing concern with Rubashkin's - this comes from the Conservative movement's rabbis. But the grass-roots activism comes from the Orthodox (albeit the most liberal).

A bright-eyed fish (or: how do you write "ghoti" in Yiddish?)

I had the pleasure just now of holding in my hot little hand a sample copy of Eyn Fish Tsvey Fish Royter Fish Bloyer Fish, our new Yiddish translation of Dr. Seuss's ichthian classic. It looks yellow and lovely and typo free. (Jinx!) More details when the whole shipment wends its way to us from Singapore. Save up your pennies!

(The cat and the monkey you already have, yes?)

PTSD in the military

The findings suggest that psychiatric disorders in Marines are diagnosed most frequently during the initial months of recruit training rather than after combat deployment. The disproportionate loss of psychologically unfit personnel early in training creates a "healthy warrior effect," because only those persons who have proven their resilience during training remain eligible for combat.

Saving a life - according to the doctors

A conversation in the bikur cholim room:

"Doctor, if a man had chest pain, can he walk home for two hours [on Shabbos]?"

"It depends what kind of pain."

"The doctors said it wasn't heart pain. Can he walk home? I don't think it's safe to walk home. The rabbi said he could take a car home."

From this conversation (which went on for some time) I learned a number of things. One of them was that the guy in question (who got to ride back to Borough Park on late Friday night via car service - I wonder if he got dropped off a couple of blocks from home?) has 11 kids in his house. No wonder he's having chest pain.

The other was that the Satmar rebbe (the recently deceased one? one or more of his quarreling heirs?) apparently was of the opinion that presenting to the hospital with chest pain was enough of a sofek pikuach nefesh to make riding in a car on the Shabbat permissible.

This raises all sorts of questions, predominant among which (as usual) is whether this opinion as relayed to me by Some Random Satmar Guy is faithfully rendered at all. Maybe the Satmar rebbe (or various present-day quarreling rebbes) holds nothing of the sort. If that's the case, never mind.

However, let's assume that the above rendering is true. Then two questions: (a) is a doctor the right person to ask for the definition of sofek pikuach nefesh? (b) if a doctor is the right person to ask, how would she judge?

A doctor might not be the right person to ask because one might hold (I don't, but one might) that halachic categories are to be determined by halachic authorities. Just as pikuach nefesh has a halachic cutoff (several, actually, but "a dangerously ill person" being the most prominent among them), so does sofek pikuach nefesh. The problem is that while there are intricate discussions about the precise definition and interpretation of safek sfeika, the issue of sofek itself is something I'm not aware of any conclusive opinions about. Is doubt probabilistic, intuitive, psychological?Thus even the strict constructionists - which I am not - who believe in immutable and exactly specified halachic categories would have great difficulty specifying a sofek pikuach nefesh, let alone a pikuach nefesh, without the help of health workers.  

The question is, how are we to translate halachic categories into medical ones? There are sick people who look terribly ill to the layperson but a doctor knows (or is said to know!) that these people will get better. The converse is true. 

Then it is not rabbis alone to whom we need to have recourse in the definition of sofek pikuach nefesh (as I write this I more and more realize that pikuach nefesh itself has the same definitional complexities), but health care professionals (most often doctors) together with rabbis. 

I don't think doctors can make the definitions; that's for halachah to work out with their help. But doctors do need to figure out some way to translate their thoughts into lay-cum-halachic language. And that is difficult, for epistemologic, not just lexical reasons.

In the next post I consider how a doctor might answer the question, "Will I die with this chest pain, doctor?" In the interim, though, consider the possibility that the doctor is not the right person after all, but the community. 

An example of this position is found in an interesting article by a Rabbi M. M. Farbshtein (I don't know if I'm transliterating his name correctly) in the journal Assia (my translation):

[T]he question up to what level of possibility [doubt, sofek] something is considered sofek pikuach nefesh does not have an objective answer, but rather [is according to] the assessment of the community that the activity was done for the sake of saving a life [pikuach nefesh]. The situation in which such an activity is required is considered to be "sofek pikuach nefesh."

The question then becomes: what community are we talking about, and how does it decide?

That's too big for now. We'll return to the doctors in the next post. What does "risk of death" mean for a doctor contemplating a patient with chest pain?

Phrases I could say all day

Seronegative spondylarthropathies!

A letter to Sholom Rubashkin

Read the letter here. ("Effective June 15, 2008 we will stop patronizing any restaurant which serves your meat.")

Patient docility

Some call it patient compliance; the more current term is patient adherence. Retro is cool now, though. (I know a guy who wants to call Yiddish zhargon again [translation of headline: "Say it in Zhargon!".)

So we might as well follow the retro trend and call it patient obedience. Just like they should have termed it with all honesty in the good old days.

I love American Spanish!

The picture is from a bathroom in the Bellevue adult outpatient medicine clinics. I also know the phrases apretar el botón or tirar [de] la cadena - but I like floshar much better.

In our Yiddish at home we say aroplozn dos vaser; I know people have also said (op)shvenkn dem klozet. Of course, just like American Spanish, in American Yiddish nowadays 99% of people say (I bet) floshn. I use that word too, with guilty pleasure.

What do you know and when do you know it?

Doctors and patients think differently. One way to understand this difference is to ask the question: how do doctors and patients know? If we try to understand our own ways of knowledge (epistemology), how our patients might know, and how the two differ, this might be productive for our practice of medicine and our patients' health.

See my poster on the topic. When you're done looking, check out the thought-provoking companion exercises. Lastly, make yourself a cup of tea (Lapsang Souchong), sit down, take a minute, and write down your epistemology on a piece of paper. Please e-mail that epistemology to me; I'd like to start a database of such statements-of-epistemology. So far I have an N
of ... 1.

Bris reprise

Summary, pix.

Cheshbon, please!

I'm sorry we had to read another Forward article with the headline "Venerable Journal In Language We Don't Read Closes Its Gaping Mouth" - and I do agree with some of the basic facts: less readers of Yiddish, less writers of Yiddish, blah blah blah zzzzz. (Fewer Yiddish letters, even. Now there are only 16: we had to lay off everything after samech. Sad.) But pleeze, if you do have a Yiddish journal, or care about Yiddish writing (yours or anyone else's), don't expect my pity until you do your utmost to share the wealth of the words you care for. Make sure your journal gets to those who want to read it (I didn't even know the journal still existed - too late now, I guess)! Make sure, for goodness' sake, that your journal has a Web page! As Miriam Koral points out: make sure that you are training your successors! Don't blame the younger generation (thanks for the sneering assessment of your juniors in the last sentence of the article, Mr. Departing Redaktor!) until you get to know them.

EBMBS

What is the effectiveness of pediatric CPR?
What is the effectiveness of laypersons' pediatric CPR?
What is the effectiveness of classes for laypeople about pediatric CPR?
What is the effectiveness of e-mails advertising classes for laypeople about pediatric CPR?

A bris!

Details on request.

Pesach cleaning: universal and particular

I love driving out the leaven. But when I talk to the third or fourth Spanish-speaking immigrant patient who couldn't visit her doctor (me) for weeks before Pesach -- she works for a Jewish family, who "can't give her much time off"-- then the phrase fiestas judias begins to sound a little funny.

* *

I wanted to go memorialize the Warsaw Ghetto uprising, but it's too close to Pesach. I suppose this should make the historical memory even sharper: in varshever geto iz itst khoydesh nisn ("in the Warsaw Ghetto it's Nisan now" -- Binem Heller).

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.")