Monday, February 11, 2019

Lasted 15 Minutes

While not really wanting to burn the SERMO bridge, I do not want to become like Elazar ben Arach either.  For those unfamiliar with the tale, he was the rabbincal prodigy determined by the President of the Rabbinical Academy to be of the highest potential, at least what he said in private, though he promoted somebody else in public.  Those who study Talmud today, which is a lot people, rarely study Elazar ben Arach's insight.  This talented youth became a mediocre intellect in his prime years.  At the insistence of his wife, who was left behind in the rabbinical social whirl, he accepted a position as sage in a resort area away from the center of learning.  On arriving there he had a vision of elevating their residents and exposing them to state of the art Torah analysis.  Instead of them becoming more like him, he became more like them, hanging out in the warm springs that made the area attractive to the neglect of advancing himself professionally.  Eventually he attempted a second act at the central academy but it was clear to himself and others that he was no longer their intellectual peer.

Rather than hoist my Libtard banner against persistent sloganeering inciting reaction for the trivial, I opted to just ration my time.  Three days a month, the day ending in zero, which makes only two in February, I set my timer for 25 minutes, scroll through the comments that have appeared in previous ten days and respond to up to three, medical or not.  At 25 minutes I sign out, returning briefly the next day to see if anyone responded beyond my remarks to those threads.  To my chagrin, my interest lasted only 14 minutes and a single comment.  No risk of becoming like Elazar ben Arach.

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Tuesday, January 15, 2019

The Zipe

One who learns from his fellow…a single law…must treat him with respect. For so we find with David, king of Israel, who did not learn anything from Achitofel except for two things alone, yet he called him his "master," his "guide" and his "intimate"… (Ethics of Our Fathers, ch.6:3)

Image result for irving zieper mdFor some unknown prompting, maybe in response to current events, my mind gravitated one recent day to my esteemed neurology teacher, known to us as The Zipe, an abbreviation of his real name.  He passed away in early 2018, after a very distinguished career with a substantial obituary in the Boston Globe imported to legacy.com.  I would have remained unaware of this had is impact on me not transferred from the storage neurons to the more frontal ones.  At the time of my residency, The Zipe was in his prime professional years, approximately age 50.  He had been a veteran, a few years junior to my father.  The obit was not clear if the military preceded or followed his medical school years.  Capable neurologists were readily available but capable and colorful seemed in shorter supply.  In a Catholic environment, he was recognizably Jewish, a member of my synagogue not far from the hospital.  




Two stories stand out.  On a neurology rotation at Boston's main VA Center, The Zipe had been assigned ward attending.  We had a big group, headed by our senior resident, a somewhat compulsively thorough Radcliffe College/ Hopkins Med alumna with a childhood origin from a different stratum than the Zipe or me.  I was one of the junior residents and I think we had interns and I know we had at least one student.  Teaching rounds were conducted in a conference room rather than at the bedside, which the senior resident could handle very capably herself.  At one session, The Zipe wanted to demonstrate deep tendon reflexes to the group.  At the time, and maybe even now, neurologists were the last specialty to carry the classic black leather bag.  I had one too, a bulk purchase by my second year medical class.  They needed various equipment, from a reflex hammer, to visual cards, prescription blanks, a variety of tuning forks to test hearing and vibratory sensation, something to test olfaction, typically a vial of coffee, maybe a hat pin to test sharpness with the point and peripheral vision with the mother-of-pearl head.  The reflex hammer was usually not the rubber tomahawk that residents kept in their pockets but a more sophisticated torus with a weighted rubber edge held by a long plastic handle that had a pencil type point at the end to test sensation.  Too big for a pocket.  


Since The Zipe needed this reflex hammer, in the fashion of the 1970's he barked to the medical student:  "Hey Student, gimme my reflex hammer from my bag."  On lifting it off the table to get it, the student noted that The Zipe's black bag was a lot heavier than his.  He opened it, reached inside, and blanched with an "Oh My God."  Instead of pulling out the tool The Zipe asked for, he extracted a rather heavy pistol.  There's always one resident wag who asked whether this unexpected equipment was intended to test hearing or pain sensation.  The Zipe asked the student what was next to the gun in the black bag.  He pulled out a prescription pad.  The pistol was to protect those papers which even unsigned had street value and whose presence made the carrier, in this case the doctors, vulnerable.  The reflex hammer was also in the bag and retrieved next.  Our lesson proceeded. I have never felt any inclination to carry a weapon to protect my person or possessions in my professional capacity, but over the years, whenever an attack on a physician made the news, I wondered if The Zipe would have prevailed if he were the intended target.

His more enduring impact on me, one that likely made me think of him again, occurred at bedside rounds.  A consult had come in to assess a man who had been prematurely losing his mental acuity.  As students we are taught the elements of an orderly mental status exam and carry one out at least informally on all the patients we see in the hospital from then on.  People are usually obviously able to provide a history and converse normally or are obviously demented so the checklist of 



  1. Judgment
  2. Orientation
  3. Memory
  4. Affect
  5. Knowledge
  6. Attention span
  7. Insight
tabulates quickly and informally.  When not obvious, there is a process for sorting this out.  The Zipe took us to the bedside to see if this veteran was prematurely demented.  He could carry on a fluent conversation, had little understanding of why he was being evaluated and knew he was in the hospital.  As was common among VA patients, and Boston citizens in general, he consumed a fair amount of alcohol.  Patients are asked the day of the week, who the President is, what the weather was like yesterday, where they served in the army which would reflect remote memory, and to start from 100 and count backward by 7's.  This fellow was a little iffy on some of the responses.  When asked the name of the President, though, he responded that he avoided politics, which were a lot less toxic then than they are now.

The Zipe completed his assessment, already done by one of the residents the day before, then back to the conference room for discussion.  Since this affable patient could get by until his deficit was exposed, the discussion involved what is and is not a true deficit.  People are just expected to know who occupies the White House as an unavoidable part of being immersed in a seeing and hearing environment in America.  People are expected to be able to subtract 7 from 100 irrespective of their education.  Even somebody who makes their living as a bank robber understands thou shalt not steal, but consciously selects to violate this.  Insight and acquisition of knowledge along with its retention are what make us a durable species.

In our contemporary environment, two generations of neurologists beyond The Zipe, people are a little uneasy with the various public presentations and rationalizations for the very reasons The Zipe tried to teach.  There is something fundamentally wrong about caging people along the border and separating children from adults.  Rationalize it any which way, it violates the CNS evolution of knowledge and insight.  Denying ethnic targeting when any observer can recognize it, something very common through American and World History, falls below the mental expectation that The Zipe, or me as his medical descendant, would have for normal CNS function.  These realities either did not exist or were dormant when The Zipe presided in his conference room.  Realities change, core principles of how a brain should be able to reason do not.

Very few teachers shaped my reasoning skills more than The Zipe, which is probably why my mind automatically migrated back to that indelible imprint just as valid today as when I sat in his conference room or a few rows from him at synagogue.


Sunday, December 23, 2018

Medscape's Best and Worst

As each calendar year reaches its conclusion, many organizations attempt to compile best and worst lists, be it TV shows, movies, cars, people of prominence or infamy that bring character and maybe immortality to the year that will soon fade into history

Medicine like any other pursuit has its heroes and its scoundrels.  I would take a safe guess that all physicians can name in an instant the five teachers who shaped them and the five guys they thought should be reported to the state board, if not the FBI.   For the bad apples, we contented ourselves as residents to mostly scoring them with a lot of zeroes on our attending physician evaluation form but never pursued anything seriously punitive.  For the benefactors, we not only gave them higher scores but assimilated some elements of their revered practices into what became of us professionally forever.  We know who they are and what they did on our behalf, even if nobody else does.

We also come across medical colleagues who we do not know but find their way into the medical and secular news for their exceptional deeds that reach beyond our personal experience.  Some win Nobel Prizes, some swindle Medicare.  In recent years we have passively received enough lurid news in print or electronically that it registers as our daily expected dose of world affairs.  Some respond, most don't but file some imprint deep into the cerebrum where it might be retrieved if ever needed but does not stay with our awareness for very long.  At the other pole, when we attend our annual meetings, some physicians get awards while we sit in the audience and clap.  Professional achievement always gets our admiration.  We see the news of physicians gunned down, including a personal college friend killed in the Pittsburgh synagogue massacre or by a disgruntled patient, usually not the superstars of medicine but professional colleagues who get some combination of sympathy and honor for the dignity that their abruptly halted careers brought to the medical profession.

While our recognition of these physicians tends to have the trajectory of a funnel where stuff goes in the big end, gets concentrated and disappears in a moment out the small end, we are fortunate to have an organization like Medscape that identifies, catalogs, and retains these positive and negative outliers each year in an easily searchable way.  The list comes out in mid-December and is traceable at least back to 2011.  Being something of a news voyeur, I scrolled through the current roster as it came passively to my email inbox.  What makes physicians, and sometimes scientists, heroes or villains can be hard to tease out on one year's list, but by searching back about five years, laudatory and despicable themes emerge with some consistency, which may not be all that different than how we each individually assigned the best and worst physicians who we personally encountered between medical school and retirement.

The rascals have a lot more consistency, and most years larger numbers, than the exemplars.  With rare exceptions they have traded in their white coats for orange jumpsuits.  Some are outright predators, engaging in assaults on mostly female or pediatric patients.  Others engage in various forms of lucrative unconscionable care.  The scientists among us might call them errors of the First Kind, assigning significance to diseases that were not present.  The intent takes it outside the realm of error.  Patients without cancer received chemotherapy, normal coronary arteries got stented, inappropriate but systematic retinal photocoagulation, and any variety of excessive bodily invasions from sinus surgeries to repetitive skin biopsies.  While these docs seem more profiteers than predators, there is something inherently evil about intentional unneeded care.  Over the few years of my review, there were few overtly incompentents, other than a few surgeons functioning above their level of training, but generally medical schools and residencies produce capable people, though not always ethical people.  The next common category are the profiteers.  There are a lot of these.  They probably caused little bodily harm to vulnerable people so, in my mind at least, would fall one level less on my personal evil-meter.  They are more financial cheats than medical ones, though a few cut corners by obtaining less expensive medicines from authorized sources then billing for the real thing.  But mostly these doctors arranged for others to due financial processing of bogus services for financial gain but not medical harm.  There were a lot of these on each annual list.  And finally we have a handful of unfortunate people who offered suitable care but got videotaped engaging in mockery of patient or staff or fulfilling a dream of being a rapper while removing a body part.  Poor judgment probably, worthy of a worst of doctors list, probably not.

Medscape's best of doctors each year fall into more categories with too few to make generalizations of how the majority of practitioners can upgrade themselves to be more like them.  One common category of people worthy of admiring though not emulating are those whose recognition that year was brought about by their untimely death.  They did good work, for sure, but it was the car accident or plane crash while on a mercy mission that caused Medscape to include those physicians that year.  About an equal number also arrived on the annual recognition list by appearing in obituaries first.  These people had lifetime achievements, mostly in advancing the science of medicine.  Their CV's no doubt had a few awards while still functioning well enough to appreciate the adulation their work had earned.

There is another very large category of praiseworthy doctors whose medical knowledge and skill does not tower any higher than the rest of us, though their dedication and tenacity might.  Each list has physicians, mostly still alive and working, who enabled people at the margins of medical care to have better access.  Some travel into the Third World to bring this about.  Some set up rural clinics, some make a career of treating medical pariahs, the modern version of lepers perhaps, people who a lot of us would groan if we saw those patients on our schedule.

Image result for dr moe dr larryOne final category that appears on every list, probably no more skilled medically than anyone else, but who endured unusual challenges to complete their medical degree.  These include professional and Olympic athletes, refugees from war zones partly completed with their education who had to flee and reapply with some difficulty in an unfamiliar country with a new language.  One started as a patient, a teenage surgical ICU alumnus with life threatening gunshot injuries who became captivated by what the surgeons were doing for him and then pursued his education under burdensome conditions but prevailed.  One does not need to be the most prodigious clinical or science maven to excel.  Pursuing a dream relentlessly is an option available to most of us in some form.

So what becomes of these people?  The medical scoundrels amass quite a lot of prison time.  Do they remain bottom feeders in custody, or might there still be some spark of benevolence that once got the favor of the Admissions Committee?  Do they sit in their cells and mope or do they impart the literacy skills and science aptitude that they have to be of benefit to other inmates who had less going for them at the time of their arrests than the doctors did?  There are medical reporters for Medscape and elsewhere that could pursue that direction.

And the Top Docs who are active, do they continue to inspire colleagues and patients with that same persistence they used to excel so that others might be more dedicated to self-management and responsibility for the diseases that they have?  Appearance on the Medscape exceptional list should have an enduring presence beyond the 15 minutes of fame or infamy that Andy Warhol thought all people are entitled to have.

Wednesday, December 12, 2018

License Renewal



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Every two years, the state has an obligation to its inhabitants, or not even inhabitants but also those who traverse borders to get their care, that the people offering that care in exchange for their livelihood have a threshold of training and character that justifies this.  It's a little harder to certify skill, but education makes a reasonable surrogate, or at least one that is easy to document, not very different than quality measures imposed on us in practice that give the illusion of quality in lieu of the real thing.

My three licenses have come from my state of residency training, lapsed many years ago as the maintenance requirements became increasingly onerous and expensive, justifiable only for those still hostage to that Board for their livelihood.  I have maintained one in my state of residence, where I also maintained a solo practice for 20 years and in the state where I practiced for my final eight years, retiring a few months ago.  On the off chance that I might want to do some locums tenens in one of those states, and the fee not being too exorbitant, I opted to maintain them one more time.  One comes due in a few weeks, renewal submitted electronically with MasterCard authorization, with a prompt email notice of approval.  Pennsylvania has a retired physician option which waives the educational requirements but not the fee so it pays to just do the Continuing Medical Education for now.

Unless one has been accused of activity unbecoming of a physician, which is not a lot of people other than maybe malpractice accusations which need to be acknowledged but do not disqualify, the barrier to renewal rests with the CME needs.  Like my other states, and a fair number of my insurance credentialing criteria, Pennsylvania requires 100 hours of CME spread over two years.  Category 1, the type that gets certificates of completion is usually the most difficult to obtain and sometimes requires a fee, only has to be 40 of those hours.  Much more, and the Commonwealth might have to deal with de-licensing their rural physicians who either do not have access readily or would need too much time away from  the practice to accumulate that much, which would run counter to the mission of making competent medical care available.  City slickers, which is me, just pick from the Grand Rounds or online options.  And since Category 2 can be interpreted loosely, medical writing in my case, consultation, lectures, mentoring medical students, it is readily available to rural physicians and accumulates in the course of ordinary physician activities. 

But there is always fine print.  Twelve of those hours need to be in risk management education, which can be interpreted rather broadly.  Medpage Today used to have an agreement with the University of Pennsylvania to certify what qualifies as risk management and offer a UPenn certificate of completion.  The University dropped their participation but Medscape Today kept the same classification, so when in doubt it is safe to assume that qualifies.  It comes in quarter hour increments so you could be doing dozens of those articles and questions to come to 12 hours.  Grand Rounds with appropriate titles do not require a learning exam, so that's probably the fastest way to accumulate these over two years.  I got six that way, the rest online.

My home state of Delaware found itself in a pickle a decade or so back when a pediatrician turned out to be a sexual abuse predator.  As unusual as this is, Delaware followed by many other states including Pennsylvania, enacted a series of child protective laws and require all licensees who might have occupational contact with children to take a course in what those laws are and answer some questions to make sure they are understood.  It's fairly easy, but takes a full three hours, for physicians who are highly literate and used to taking reading comprehension tests to do this.  The requirement may be more difficult for some of the holders of other occupational licenses or others without a state license but occupational contact with children who have little formal education or familiarity negotiating a computer course.  Printed certificate in CME folder.

Finally Pennsylvania officials are still uncertain whether their docs are the cause of a dangerous expansion of opiate use among the state's citizens, or maybe the best resource for its resolution.  A two hour CME module on opiate prescribing was added to module, probably irking the pathologists and radiologists whose patients are beyond pain. 

Done.  $360 added to my next credit card bill.  Maybe an audit somewhere in the next year or two to see if I am more truthful than our current President, which I perceive myself to be.

Those fees are a big windfall for  the Commonwealth of Pennsylvania, which has a lot of doctors.  There are disciplinary proceedings that the Board reports from time to time but I do not think I have ever personally known a doctor cited.  Level of skill varies, but I think everyone exceeds its threshold.  While I am technically permitted to do brain surgery but don't know how, some self-screening occurs and for those who really want to practice above their level of skill, there are other credentialing mechanisms of hospital staff membership that keep the medical Walter Mitty's in check.  And when all is said and done, those 140 hours of CME category 1 that finally accrued probably added less to my skill than the board might have hoped, except for the 22 obtained at my national specialty meeting.  But pursuing medical knowledge for the sake of mastering it has its psychic dollars, so I really didn't mind the effort.  And it's likely the last time except for a minor provision I will need to satisfy for Delaware in the coming months.

Tuesday, December 4, 2018

Almost Like It Was

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It had been my intent to sign back into Sermo the first day of Hanukkah, leaving me with an absence of a few months.  It's the longest I've been away, not even a lurker, and had no interest in being a lurker on return.  At one time Sermo absorbed a lot of my free moments, and even my productive ones.  I would engage in discussions, make fast quips, use the Endocrinology cases that people posted and commented upon to teach my residents on elective with an analysis of the various comments that individual respondents would make, some expert, some less familiar.  Like much social interaction and media, an element of echo chamber became increasingly apparent.  The best scholars both in clinical medicine and in general erudition had moved on.  In retirement I could have depleted all day there, but as my electronic colleagues became less endearing, I gave myself a limited hiatus which concluded yesterday.

My time back was intentionally brief.  Much like you cannot tell the difference in your kids from one month to the next but their aunt who has been in the hospital can, that's what I found.  Scrolling back about 5 days, the subjects and posters had changed, mostly for the better.  Libtard this and libtard  or related sloganeering that so dominated titles of recent years, did not appear in any meaningful volume.  At my exit there were a handful of folks who I thought might be trolls, probably not paid to pitch the political hardball five times a day but self-motivated to see how much of an electronic gathering they might generate.  The physicians I would walk across the electronic street to avoid had disappeared.  A few frequent flyers remained, a fellow who was still between jobs when I left, a fair number of physicians still moping about administrators and insurance companies who'd done 'em wrong, a lot of stuff that might come out verbally at a Medical Staff Christmas party.  I engaged in a few of the conversations, one by a lady who had taught herself to read.  I was taught to read in two different alphabets but would have failed if I had to do it on my own.  One conversation involved the demise of the prestige that once accompanied the MD or DO degree.  True enough, but I decided a long time ago that my self-esteem did not depend on my possessions and my diplomas are my possessions.  My knowledge and skill are shared, and seem to have been appreciated right through retirement.

There were people creating threads who I did not recall from months past.  One had the nom du plume tushi, a fellow from a developing country.  The censors are apparently more tolerant than the state motor vehicle divisions who might have censored that from their vanity plate roster.

Being there had very little emotional impact.  Not offensive.  Not an echo chamber.  Better than when I had left but without the return of the dozen sharp minds of years back whose comments I made a point to read.

An obscure but important book about recapturing a waning Jewish organizational culture in America came out about ten years ago, Getting our Groove Back by Scott Shay, a rather well-to-do NYC banker of Orthodox background.  He devoted a chapter to the attrition of Conservative Jewish affiliation, regarding the loss of the middle as one of the great American Jewish disasters, which it probably is, no matter how self-inflicted.  I think the departure of the best and the brightest who contributed their articulate analyses to clinical and non-clinical aspects of the American medical pageant approaches a disaster for the American medical community.  The forum remains but its previous glory does not with no means of recapture, other than maybe hiring their real scholars and conversation makers as the more beneficial trolls paid to post.  Every bit as self-inflicted as the leadership generated attrition of Conservative Jewish institutions but a public loss just the same.

Have I passed through the exit door for the last time?  Probably not, though even though the offensive posters seem gone, beneficially provocative replacements needed to enhance an attractive physician forum don't seem all that highly desired.

Friday, November 23, 2018

Abandoning SERMO

Image result for posting sitesBeen reading Robert D. Putnam's iconic Bowling Alone on declining social attachments, which is probably applies to the medical profession as much as anything else.  He notes a number of transforming events, now and historically, including the rise of corporations and cities before 1900, the diversion of people from work to entertainment with the movies after World War I and TV in my childhood years.  The book has a publication date of 2000, which is the time  when people became connected in cyberspace.  He had no means of knowing the impact of this and it remains a social process in transition, but there is a precedent of the telephone which connected people over distance but mostly people you already knew.  Posting sites have changed that aspect of the landscape, an immense opportunity that may be going bust.

Medicine has had personal interaction for a long time.  You knew your local colleagues, mostly as fellow physicians, sometimes also as friends or other social acquaintances.   People you didn't know would post their research at regional or national meetings where anyone could discuss there work face to face.  But these are not really friendships.  Come the Internet and now an obscure nobody like me who has an MD and sees patients finds himself invited to be a member of the community, be it Physicians Online which became Medscape, Doximity, Sermo, or for less populated but more substantial give and take, KevinMD.  Facebook arrived at about the same time, a mixture of people I knew from high school who were dormant but real friends and strangers who had common interests, sharing a hometown, cooking mavens, or bloggers.  And let's not forget the predecessor, AOL chat rooms where the 40-somethings were impeccably polite, my fellow Jews less so, and unwelcome troll Abdul with a slur that instead of hitting the ignore button, people would respond back.  Abdul succeeded in interrupting pretty much all conversations.  I do not know if these chat rooms remain but I've graduated from 40-something.

In person, people are mostly gracious.  There are ornery patients but as a professional who has seen this before, I never felt victimized in any way, just fulfilling my duty to these people as best I could.  Objectionable members of the public were also expected.  The pool of ornery patients is a subset of these people.  I've never met an actor who played a TV villain but I'd probably judge him that way if I did.  We now have public figures who are cheered on as they become the surrogates for overriding social norms that would violate our Codes of Conduct at work.  With few exceptions, they underperform me professionally, educationally, and in all likelihood economically.  They may be patients, we may cross each other in the supermarket aisles, but for the most part they live someplace else.  Prof. Putnam's more recent work suggests that they and their next couple of generations fulfill the Biblical edict that misconduct perpetuates down generations.

What I did not expect were physicians who when given anonymity would start expressing some pretty vile social ideology that they would not want attached to their office entrance with their name on it, while other similarly anonymous colleagues cheered them on.  It's never exactly like Abdul making reference of "Death to the Zionist Swine" on the Jewish discussion sites, but it is the expression of an id that would remain prudently tacit in any on-site medical encounter.  My professional colleagues have mostly been personally cordial even when there have been rivalries and once in a while limited respect based on real interaction.  And this predates institutional Codes of Conduct and Disruptive Physician edicts though it may be more understandable now why our employers make us sign a statement that we have read them.  Committee meetings could have contentious issues but we never called anyone dumb or incompetent or evil, even when it might think that.  But once your presence is a keyboard and avatar, in the absence of comment moderation, it did not take long for Medscape to become Mudscape and for the parent company to realize they could not fix a problem that caused some of the most talented contributors to depart, resulting in withdrawal of that part of their service to their participating physicians.

The premier forum, though, has been Sermo, for which I have been a member physician for many years.  It has some advantages, not the least is being limited to licensed physicians.  One can register in a minute or two.  Physicians are asked to choose a screen name.  A few keep some abbreviated variant of their own name, but most search the creative portions of their hemispheres for something unique.  People are identified by specialty, which is essential in some of the clinical conversations where it becomes clear who does the medical tasks professionally and who dabbles but is opinionated just the same.  I started there a number of years ago, I forget how many, flattered that they would have me no questions asked other than my state license number, and immersed among people who I have never met but shared their medical knowledge, often a profound intellect that can tease out the nuances of our professional EHR and insurance challenges, take interesting vacations, and engage in various political discussions in the way that friends would.  That was the nascent Sermo.  We had conversation makers, a few provocative thinkers, evangelicals and atheists, and most importantly that silent expectation of reciprocity where they could express what they want, I could express what I want and we'd be on the same page with next week's exchange.

That did not last indefinitely, maybe in parallel with larger American trends.  Discussions with reasoning underlying what you were writing about devolved into the more crass sloganeering, sometimes targeting people.  The Islamists departed first as gratuitous attacks became something of an expectation.  The really astute analysts came next as any reasoned mini-essay would find a bunch of trolls making snide remarks about libtards instead of refuting the merits of what was written.  Before long there was a Code of Conduct, and a few deactivations of various lengths, usually for clear personal attacks.  But it was no longer a discussion forum worthy of people who succeeded personally and professionally by being at the top of their college classes.  People whose minds I held in the highest regard started limiting themselves to clinical input, where their expertise could not be reasonably challenged and the rest of us could advance our own knowledge, but the community which started in the right direction had begun to fritter its intellectual capital.  At about the same time, there was some awareness of this communal atrophy with a number of frequent posters noting the absence of some of the most revered participants.

About two years ago, I began wondering whether I also needed an absence, starting with two weeks, repeated a few times.  Then last year, a month, which turned out to be one of my most personally productive, adding to some of my own professional writing, diverting it from Sermo to KevinMD, which meant selecting a single idea and expanding on it.  The downside was that it was limited to medical commentary.  I handled it in the manner of a Nazir.  If unfamiliar with this, a Nazir is a person in Torah who takes himself voluntarily out of commission for a specified time, does not drink wine, cut hair or come in contact with a corpse.  At the completion of this hiatus, he must bring a sin-offering for having voluntarily deprived himself of what the world had to offer.  If I said two weeks, it was two weeks, if I determined a month, it was a month.

This time it's different.  I specified three months to be concluded at the start of Hanukkah.  For a very short while I was itching to type and each Sunday for the next month, the Sermo headquarters would send me an email with how many helpful clicks my comments had accumulated the previous week.  It took a month for them to disappear, much like the last time I was away for a month.  But this time after a few weeks, I found myself indifferent about returning.  Not eager.  Not hostile even though I had left partly due to annoyance and partly to protect my own analytical skills by doing other things.  Indifferent, that emotion which Elie Wiesel, z"l, repeatedly described as the real opposite of love.  I was indifferent and still am as my separation nears the pre-determined return date.  I'm not sure I want to re-immerse myself or if I would be more tolerant of the current reality in my previously preferred virtual community, having no realistic expectation that the people who energized my mind but are no longer there would be replaced by new analytical minds.  Yet I have that not quite promise to myself to restart at Hanukkah.  I always had the option of unsubscribing but never did.  The service still sends me emails of weekly highlight postings that I haven't opened and surveys that screen me out as soon as I click retired status.  It's not the only medical forum that I have, since KevinMD though smaller, has avoided the sloganeering that turned the best thinkers away from Sermo.  And I have started going to Grand Rounds at two medical centers where I see former colleagues who have hands to shake.  But Sermo remains a community, or maybe in its current circumstances something of a dysfunctional family.  It's not always apparent which ties bind and which ties restrain.

Tuesday, November 6, 2018

Massacred

Among the victims of the Tree of Life Synagogue mass shootings was my college friend Jerry Rabinowitz, MD.  Jerry and I shared a lot of classes and remained friendly.  Graduation separated us for the ensuing forty years with an occasional professional snippet from an alumni source.  It came as no surprise that the tributes that followed his murder lauded both his kindness and his dedication as a physician.  It was my honor to have known him in our formative years and to take satisfaction in his personal and professional success.

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