Not on Weekly Schedule

Every Sunday I outline my weekly schedule on a white board.  If it's a day ending in zero other than Shabbos, Sermo gets a notation in green marker, though not this week.  I'm just no longer interested. 

It's not the first social media that I've abandoned.  There was a great site called classmates.com, great only if free, that predated Facebook.  I reconnected with a lot of the old crowd that way, dumped en mass when a fee was added.  I used to chat with the 40-somethings every morning and some Jewish group chat in the evening.  Screeches from Abdul were worthy of mass use of the Ignore option but enough participants preferred to engage him and the site no longer was attractive.  Physicians Online introduced me to cyberspace.  They had a physicians chat or posting room.  It did not take long for it to appear as a talk radio echo chamber.  As Physicians Online became Medscape, they made a business decision to abolish the service rather than police it.

Sermo once served as a daily destination, a place to make virtual friends.  It took longer for the echo chamber to take over, but it eventually did.  My sign-in dwindled from daily to dates that end in zero but until now remained on schedule.  The new format did not help, hard to navigate, more international posters with concerns different from American physicians, and most importantly, lacking the sharp analytical minds.  Just not on this week's weekly planning.  Not interesting and really not interactive, which could take the mundane on more intriguing directions.  But they still do not charge a fee.  I'd have been gone long ago if they did.

Doctors in the Wrong Half

http://furrydoc.blogspot.com/2019/10/two-americas-reaches-doctors.html 

I try not to merge my personal blog with my medical one, or even immerse myself in political positions, but the intersection here was just too inviting.

For whatever reasons, I am situated in the prosperous part of America as are my children.  We have professional degrees, economic stability, take personal and political positions that are in strong opposition not just to depravity itself but to its enablers.  It's part of the politically Blue America with little crossover and barriers to entry to those not already there.

Many doctors seem to have averted this intersectionality.  Sermo in my opinion has deteriorated, not just changed, into an echo chamber of thought that the posters probably wouldn't want on their office doors with their real names and Photo ID's.  Yet they have my same education, most a higher income if not greater net worth.  I don't know any of these frequent right wing posters personally, and very few in my professional interactions.  I suspect they are not the cohort that gets invited to present at national meetings, as medicine has its upper and lower hierarchy just as medicine does.

I suspect that we have slid in the direction of wage earners besieged and trying to hang on in an increasingly insecure professional world.  It comes not only at the expense of the autonomy which so many of us mourn, but also at the inherent dignity of medicine.  The posts that increasingly dominate Sermo are a too often long way from benevolent with virtually no one interested in refuting it.  If I, as a person loyal to medicine opt to walk away from this forum rather than stake my claim, it won't take long for the public to appreciate this as well and write us off as the Lesser Half of America. 

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.

Almost Like It Was

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.

Abandoning SERMO

Been 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.