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


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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Friday, September 21, 2018

Young Adult Trauma as a Marker of Later Health

In my final working weeks, my medical center had cemented an agreement with the Veterans Administration to offer care at our center to veterans who could not be accommodated at the VA for a variety of reasons .  We could use paying patients, they could use doctors of our caliber so our representatives established mutual benefit.  We have always had patients who have served in the military.  For much of my professional life, that has included most men of my father's generation whose young adult years encompassed World War II with its widespread draft.  World War I and Korea conscription was less universal but patients having served in these settings were frequent.  Vietnam service seemed more selective.  For the most part, even when employed as a VA physician 1980-88, the patients' service while appreciated was largely parenthetical to their congestive failure, COPD, or diabetes.  Some had permanent sequelae of their service, missing limbs, shell-shock or post-traumatic stress disorder depending on which military conflict, a chemically related setback often still in adjudication where medical care intermingles with compensation.  Some were more indirect, the many alcoholics or other substance abusers, maybe some of those with hypertension, but these were also highly prevalent in people who never wore a uniform.  But by age 60 when people started getting admitted to the hospital more frequently, the diseases I treated at the VA did not seem very different from those encountered elsewhere, at least on the Internal Medicine service.  They got admitted, I took the best care of them that circumstances would allow for whatever I thought they needed.  In the community hospitals and in the office, I shared patients with the VA though separate payment systems, and people came by who just happened to have been in the army as young adults but were pretty mainstream thereafter, going to college, joining a union, maybe for some latching onto a business, or seeking jobs as they became available without ever acquiring an identifiable occupation.  As prescriptions became more expensive, the VA would often supply medicines to veterans like my father and others who saw the doctor or nurse practitioner as a precondition for having the prescription supplied but regarded physicians external to the VA as the doctors they made most of their appointments to see.

With systems, particularly governmental ones, process often becomes excessive.  This being an important medical center initiative, the first Grand Rounds of the academic year went to the VA's physician representative to this project.  He outlined process.  Every patient admitted to the hospital would have a complete military history, where they served, which unit, injuries, illnesses, anything that might connect to their military service.  This seems to me like a good invitation for some errors of the first kind, those Type I errors that attribute significance to what is non-contributory to the hospitalization.  Even at the VA itself, by the time somebody is 60 years old and has an MI, it was not the military mess hall that made the cholesterol high.  And the need to fill out what may be too comprehensive a questionnaire runs the risk of distraction from more vital information gathering and examination that has a more immediate effect on the encounter of hospitalization.  What we may be doing is propagating an event of young adulthood, labeling it as an imprint which portends an invisible forty year interval until they come to our ER.  I think the process needs to be more selective than what the speaker described in his presentation to be meaningful.  In this era of Electronic Health Records, we already gather reams of historical information that never gets refined or prioritized by its importance, since we often don't know its importance.  Or as the New York Times advertising once told its consumers, "you don't have to read it all but it's nice to know it's all there."  However which portions you read matters a lot.  If the military history acquires an inflated importance by the very time allotted to it, the more immediate medical imperatives risk distortion as well.

The other consideration would be why select military service as the shaping event that forms the underpinning of once's health at some time in the remote future, then trying to reconstruct this in reverse?  In attendance at this Grand Rounds were our residents.  At age 20 they had a fair amount of academic terror, fretting over the Organic Chemistry final that might weed them out professionally.  At age 25 they had The Match culminating the rigors of medical school, some overseas.  As residents many departed their families from Asia or Latin America.  And by the time they get their certificate, many will experience burnout.  Will the experience of medical training in their 20's be more favorable or less to their health at age 60?  And our city campus where I saw inpatients and outpatients has an immigrant population.  West Africa dominates as the region of origin but Bangladesh, Ethiopia, Indochina and the Caribbean are all represented.  Having had the privilege of breaking the ice with some small talk before starting the medical history, a lot of the men were war refugees who came to America as young adults.  Many of the women, particularly those of Indochina, were also displaced by either extreme poverty or a few by adverse political situations.  We have a large African American population with patients who spent their 20's in our penal institutions instead of college or the army.  No question these are all major traumatic events that have enduring impact on the psyche and maybe on health.  And lets not forget those adult patients of another era, though well within my own professional lifetime, the Holocaust survivors, some known to me as patients others as neighbors.  Military service while rigorous and formative, probably falls short of the terror to a young adult of having their families perish and fleeing to an unfamiliar place alone.  While it is expedient for the hospital to select out military service as a base of exploration, I wonder if from a health perspective it may be too short sighted.  If emotional and recoverable physical trauma at age 20 portend health outcome at age 60, maybe the source of trauma needs to be more comprehensively explored to include professional training burnout, civilian victims of civil conflict, crime victims, imprisonment, divorce or family abandonment among others.  We have ample numbers of patients in each category.  If focusing on the rigors of youthful military service make us more sensitive to the many other disruptions that young adults experience so that we consider this in a more general way than we do now, we probably will do much of our population a lot of good over time.  But we have to be careful not to engage in excessive information gathering for its own sake and stay focused on our mission of optimal health long past the traumas of young adulthood.

Thursday, September 13, 2018

My Own Advice

As a kid, I was really skinny.  A coxswain on the freshman crew team at under 120 lb.  I reached a nadir of 108 lb as a young parent with the help of giardia lamblia acquired from my infant daughter and her day care center.  Suit size 36S.  Some quinacrine resolved the infection and my weight returned and remained fairly static until my mid-30's.  During my endocrinology fellowship, I ate lunch more and gained about 10 lb,, feeling observably better in the process.  Weight gradually settled at 140 or , so, stayed there a long time, suit size 38S.  Then about 10 years ago, it rose gradually and as it approached about 160, suit size now 40S, I could tell that it needed some attention, which it got, with roughly the same result that my patients got.  I set a goal of 155, where I still felt well, got as close as 157 but intake is probably an ingrained regulated process so the new plateau settled at 165.  I still feel good, but since I am going on cruise shortly, I decided to have some clothing altered.  That venerable 40S sportscoat could no longer be buttoned.  I did not want to pay $50 for the alteration.  I bought new pants, my usual size, which ordinarily need the length adjusted.  Now it needs the waist adjusted.  Weight is not much different, distribution may be around the midsection.

Since retiring about six weeks back, I have been better than ever with diet and exercise consistency.  I have breakfast every day, I go on the treadmill two days of three with almost no lapses.  For a while supper was less and mid-day snacking less but a new feeding pattern may be setting in.  It's time to do what I tell the patients.  Pick a diet, any diet.  Minimize bread, potatoes, pasta, and rice which happen to be my staples.  Some things I can do easily.  On my kitchen table right now I have a box of Tastycake left over from my son's recent visit, a container of Trader Joe's Cat Cookies which really do not have a lot of calories and Trader Joe's Strawberry bars.  In the refrigerator I have fresh figs and baby carrots.  To my surprise a Shop-Rite crummy bagel has 250 calories.  I do not really need to make Hasidic Noodle Kugel except for a special occasion.  Keep it easy and measure. 

Keep the jacket unbuttoned on the cruise formal nights.

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Friday, August 17, 2018

Attending Grand Rounds

Image result for grand rounds medicineJust under three weeks ago I concluded my mission as clinician, following through on retirement plans set in place five years earlier, delayed by eight months to help my hospital with a transition and at the age I had anticipated ten years earlier.  I do not miss the patients or the clinical challenges they impose.  I thought I would miss the pageantry of the hospital more than I have, but I don't.  This unstructured time sorts out in stages, first being to take better care of myself.  I have an exercise schedule fully maintained and I eat breakfast every day, something that would often take a back seat to the pressures of the clock and the morning commute.  On the advice of a weight control expert who lectured at the Endocrine Society meeting a few years ago, food is verboten from 8PM to 6AM, mostly adhered to.

Part 2 is to get my personal space fully functional.  While a Man Cave seems an excessive extravagance, my hospital always provided me a functional work space which I intend to recapture at home, though it means clearing oodles of paper and obsolete electronics and kids stuff from where I intend my study to be.  Progress there has been satisfactory, limited a little by the amount of recycling that can fit in the bins that get carted off every two weeks, but so far so good.

My mind comes next.  Every six months I read a novel, a non-fiction work and a Jewish work distributed over standard book, e-book, and audiobook.  On schedule.  My journals still arrive, though I have not read beyond the titles yet.  I asked my previous two hospitals to put me on the announcement list for Grand Rounds and other conference schedules, which they did, and I attended my first yesterday.  It took place as a simulcast from the main medical center auditorium twelve miles away at the much expanded hospital in town where I once saw patients almost daily.  The speaker gave a presentation of Medical Homes, a concept that I understand better from the talk, though with some skepticism of whether the mission of better care at less expense will accrue.  Some old friends attended, some retired, some probably asking if I can do it why can't they as some were my contemporaries.  And a lot of residents attended as well.  They had coffee but to my surprise and slight disappointment nothing else.

So which will bring me back, the chance to learn and think about where medicine is headed without me or the handshakes with old friends?  A mixture to be sure.