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Goodnight Comey

Good night President who doesn’t think.

Good night Navy stewards with food and drink.

Good night door and grandfather clock.

Good night Lawfare’s nonpartisan shock.

Good night, big hooks of Rus.

Good night, Comey hearing fuss.

Good night, director (ex) of FBI.

Good night, Ivanka’s madeup sigh.

Good night, coffee.

Good night, tea.

Good night, honest loyalty.

I’m no Syria expert. (Heck, I’m not an America expert. Or a Maryland genius. Or so knowledgeable about Baltimore. Nor do I know myself.)

But Obama’s doctrine seemed plausible to me because it took into account the falsity of the “something vs nothing” framing wrt Syria. Any choice involves the deaths of innocents. Assad will kill.

Will intervening cause more deaths, or prevent them?That seems a core question. The more aggressive intervention might not necessarily achieve more robust outcomes, but merely more death and distress.

The Iraq lession is not “never intervene.” It’s “know what you’re doing before you intervene” and “intervene based on truth, not lies” — and also “have the end in mind before you start killing people.”

Why individual and community are both undermined by Trump, and both need to be placed at the center of compassionate care as part of anti-Trumpism

The righteous battle to keep ACA from being dismantled saved health insurance for millions. That was salutary in all senses. But the larger terms of the conflict are worth addressing — because they illuminate both why Trump is to be fought, and what we have to do to make healthcare work.

Read more here: https://medium.com/@ZackBergerMDPhD/patient-and-society-in-the-anti-trump-movement-dad56382515

modern-decor-lucite-giraffe-jonathan-adlerCada semana tutorizo (es decir, enseño y superviso) en la clínica de medicina interna a los residentes en las consultas externas del Hospital Johns Hopkins, en la calle Caroline en Baltimore. Los pacientes son en su mayoría de la ciudad Baltimore y afroamericanos, sin embargo recientemente empieza a acceder un número creciente de inmigrantes hispanohablantes.

He intentado algo nuevo estas dos últimas semanas. Cada vez que un residente me presenta un paciente (como nos exige la ley y la buena práctica), escucho la introducción, sonrío y luego me permito interrumpir con la siguiente petición:

-Por favor, dime algo no médico sobre el paciente.

En nuestra cultura médica, los residentes presentan al paciente de esta manera: “Sr. S. es un hombre de 69 años con enfermedad renal crónica, trastorno bipolar, enfermedad arterial coronaria, hipertensión e hiperlipidemia, acude para seguimiento.” Pero a mí me interesa cada vez más saber algo sobre el paciente como una persona con tres dimensiones, cuando no está en la clínica.

Las respuestas de los residentes a esta solicitud mía parecían pertenecera una de estas categorías.

Hay algunos que obviamente no habían pensado en tal enfoque. Uno dijo: “El paciente es muy agradable. ¿Eso cuenta?”. No, dije. Algunos residentes parecían reconocer que realmente podrían preguntar, por ejemplo, dónde vivía el paciente o qué hacía, pero les faltaba tiempo.

Otros habían preguntado sobre tales cosas, pero necesitaban permiso, por así decirlo, para mencionarlas desde el principio – para permitirse dar al amor por el paciente por los crucigramas, la devoción al coro de su iglesia y a la colección de figuras de jirafas, la misma importancia que la adherencia a la medicación y su nivel de creatina.

(Hubo incluso una residente que se rió, y siguió con su presentación – no estoy seguro si no lo entendió, o simplemente me ignoró).

Ninguno de los residentes dió dicha información personal sobre el paciente en la introducción de su presentación sin que yo lo hubiera pedido. Sólo se permiten ciertos tipos de conocimiento de los pacientes – sus datos biomédicos, sus disfunciones fisiológicas, y (algunos de) sus síntomas. Pero no su vida personal, no lo que hace que su vida – ellos mismos – les merezca la pena vivir. No ellos como personas.

Por supuesto, los criterios de conocimiento permisible se transmiten sólo implícitamente en la escuela de medicina y en la residencia. Pero son poderosos. Son una atmósfera que envuelve al médico en la clínica – tanto que incluso yo, varios peldaños por encima de los residentes en la jerarquía, me siento consciente pidiéndoles que me den una (¡sólo una!), “cosa no médica” como nombre justificativo, acerca de un paciente. E incluso entonces, debo justificarlo: “Se trata de ver al paciente como una persona completa”.

¿Qué cosas no médicas le han preguntado a su paciente o compartido con su médico?

No soy hispanohablante nativo y le doy gracias a un colega generoso de Madrid que me ha editado este blog. Por supuesto llevo la responsabilidad para todas infelicidades de estilo y errores gramáticos.

modern-decor-lucite-giraffe-jonathan-adlerEvery week I precept (teach and supervise) in the residents’ internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore. The patients are mostly Baltimoreans, mostly African Americans, though an increasing number are Spanish-speaking immigrants.

I tried something new these past couple of weeks. Whenever a resident presented a patient to me (as is required), I listened to the introduction, smiled, and then let myself interrupt with the following request:

“Please tell me one non-medical thing about the patient.”

You see, most often, the patient is presented this way: “Mr. S. is a 69 year old man with CKD [chronic kidney disease], bipolar [disorder], CAD [coronary artery disease], hypertension and hyperlipidemia, here for followup.” But I was interested in knowing something about the patient as a person, when he’s not in clinic.

The residents’ responses to this request of mine seemed to fall into one of several categories.

There were those who had clearly never thought of such an approach; one said, “The patient is very pleasant. Does that count?” No, I said. A number of residents seemed to recognize that they might indeed ask about, for example, where the patient lives or what they do, but they hadn’t had time.

Still others had asked about such things, but needed to be given permission, so to speak, to talk about such things right up front – to give the patient’s love of crossword puzzles, devoted membership in her church choir, and collection of giraffe figurines the same pride of place as her creatinine and medication adherence.

(There was even one resident who gave a laugh and went right on with her presentation — I’m not sure if she didn’t understand, or was just ignoring me.)

None of the residents gave such personal information about the patient in the lead-in to their presentation before I asked for it. Only certain kinds of knowledge of patients are allowable – their biomedical data, their physiological malfunctions, and (some of) their symptoms. But not their personal lives, not what makes their lives — to them — worth living. Not them as people.

Of course, the criteria of allowable knowledge are transmitted only implicitly in medical school and residency. But they are powerful. They are an atmosphere all around a doctor in clinic – so much so that even I, several rungs above residents in the hierarchy, feel self-conscious asking them to give me one (just one!), apologetically named “non-medical thing,” about a patient. And even then, I must justify it — “It’s about seeing the patient as a whole person.”

What non-medical thing have you asked your patient about, or shared with your doctor?

Happy Purim 2017 from Zack, Celeste,

Progressive care is in danger. Candidates to protect health for the vulnerable, evidence-based medicine, and access for all need your help. Please give today.

Also, please check out the website for our new PAC, Clinicians for Progressive Care.

It comes to mind that this should be a field day for moral philosophers, or at least those in the Aristotlean mode who like to talk about categories of virtue and what not.

Look here! We have the idiotic evil incompetents (Trump and Bannon), the principled (but evil) organizational men, doers and organizers (Ryan and McConnell), the spineless collaborators (Rubio and Chaffetz), and the unscrupulous greedy connivers (Jared). We have the passive self-justifiers (Collins), the tragic-comic bumblers (Christie), and the self-aggrandizing demagogues (Stein). We have the earnest electoral failure (Clinton) and the distant hero (Obama). We have the safe champions (Gilibrand) and the fierce persisters (Warren).
Which is the worst evil? Which is the greatest good? Let the learned speculation start!

Our first podcast of the new year features a chat with the bilingual poet/critic/translator Alexander Dickow. Text of the poems he read are at the end of this post.

To a Politician
Your cellophane disguise for a tongue
Furiously unbefits the even knavest
Of these podium fisted Catilines I hate
Whose dim broadcasts encrust
With craven abjectives and slick nouns,
Whose paramount pronouncements’
Weighty grovel fresh veneers each victim eye,
Who gape and crave at limp wealth,
Puppets of their own slanted lip
And their thin speech as cheap
As its callous stakes are ruthless:
Our brittle faith, our breath, the truth.

Galaxy

Measureless and vacant husks
Veneer along the pale gaps
Kissing the smooth-lit kernels
Far across the hesitation
Contours

Where cycles dip
Ebbing forth aromas
Of nectar vicinities
All gleamed among
Their dim stretchings

Remote surroundments
Hint around lucid cusps
And milk-blinkings swerve
Over grooved vastnesses
Whose lofty gazes
Empty to the brim resound

Finespun legions
Of distant stone pivot
Within strange rings
And innocent strains
Swivel endless and lilt
Like hearts wept upon
The rings of far-fetched motes
Tingling their ancient aubades

Galaxie

D’incommensurables écorces
Enduisent selon les faîtes espacés,
Et frémissant le semis d’éclairages,
Floue les ourlets tout loin.

Arômes qu’émane
Un jusant cousus d’oublis,
Luisez vos affleurements sourds
Et vos proches nectars.

Des avant-preuves perlent
En glissant partout les orées lucides
Où des clins de lait dérapent
Pendant des éloignements vastes
Dont les grands regards
Vides à ras bord résonnent.

Des légions respirées
En pierre lointaine pivotent
Dans des cerclages
Et des airs d’innocence
Louvoient des vibrements
Comme des coeurs pleurés
Dessus les anneaux d’improbables noyaux
Frissonnant d’antiques aubades.

Advice for Jewish Adulthood

Regarding the shower knob in hotels, whichever way you turn it is wrong.
A half a bagel is like half a dream.
If you want a cookie, and eat it fast, you will see the glimmer of the heavenly vault out of the corner of your eye.
There is only one right way to write Hanukkah.
Stand up for what you believe in and get along with everyone. Isn’t that easy? Haha! Now you understand why there are no cookies in the house.
Princess Leia wore her hair that way so to have two Danish available for breakfast at all times.
Do whatever makes you happy, but let’s talk about the definition of “happy” through weekly phone calls and frequent texts, okay?
Nothing’s funny about Yiddish. Except your father.

משנה מסכת בידחות אבא

זאָגט די משנה. דער פֿאָטער מאַכט אַ שלעכטן וויץ. וואָס איז דער דין? זאָגט ר’ מיכל, גיב אַ קרעכץ. זאָגט ביילקע, פֿאַרקײַקל די אויגן און שאָקל מיטן קאָפּ אויף ניין. די חכמים זאָגן, אַז ביידע זײַנען גערעכט. וואָס איז אָבער דער דין אַז דער פֿאָטער זאָגט א קאָמישן וויץ? זאָגט אסתּרל, אַפֿילו איך ווייס אַז דאָס איז נישט מעגלעך. זאָגט ביילקע, כ’בין שוין גענוג אַלט צו מאַכן אַליין גוטע וויצן. היתּכן? זאָגט דער פאָטער. נישט מעגלעך. תּיקו.

את תהי לאלפי רבבה
או לבת 13
תהי מה שאת רוצה
בכל העולם לגמרי

בכל סיפור שלא כותבת
בכל שפה בעולם
ה’ דרכיך תשכיל. זאת אומרת:
תעלי לעילא בסולם.

***

When I think about her bat mitzvah, I think of it — as I do any major event — on many levels. In one sense the ceremony is mainly about her as an individual, her transformation (slowly and imperceptibly, in the moment, but retrospectively surprising and sudden) into a Jewish adult, navigating between choice and obligation. This is her gift now, to do with as she pleases, to open or abandon — what a horrifying and freeing thought all at once!

But we wouldn’t be doing this ceremony at all if it was just a thing-for-her. There are many Jewish worlds, histories, and dramas in parallel, and she can participate in many of them at once. There is the drama of relationship with God, spiritual creativity, and the perfection of compassion through the high art of halacha, liturgy, and Torah study. There is the meaning-making, innovation, and searching for the usable past which is modern Jewish culture — freeing oneself from past bonds while discovering for oneself what is to be a Jew. That search is made much more difficult without Hebrew and Yiddish, languages she knows and has a connection to. Finally, there is the life of a Jew in the world, supporting a democratic, Jewish Israel which does not oppress Palestinians, and being a citizen in these free, democratic United States. As I told her after Election Day, “It’s up to your generation to fix our mistakes.” And we said together: “No pressure!”

She is compassionate, sensitive, artistic, intelligent, and (sometimes!) focused. She has all the talents and skills she needs to ask the question, “What does it mean to make the world better for both Jews and non-Jews?”, and then do it. The manner of her doing so remains to be seen. I can hardly wait.