Certain books have played outsized roles in my life. Most of these are the work not of a committee but of a unique personality. This is true of Jewish religious texts too. I have never really had a warm feeling for the Maxwell House haggadah – I didn’t grow up with it. The Artscroll haggadah is not my cup of chrein, and A Different Night, though valuable, has a little bit of short attention span about it. Here’s a picture! Here’s a poem!

On the other hand, Jacob Milgrom’s Leviticus series (for Anchor Bible), felt like a meeting with a learned, opinionated, and irascible uncle who had very clear opinions about the Holy of Holies (sorry, the adytum) and what it all meant. I was convinced, before I realized that critics are just as disputative as scientists and Milgrom’s truth was not the whole or only truth.

Similarly, Rachel Adler’s Engendering Judaism is the work of a single intelligence, though I might disagree with its ideological take. Judy Hauptman, David Weiss-Halivni, and Daniel Sperber are others who are able to convey a sense of themselves as people, not just footnotes strung on chapter headings.

This is the sort of haggadah I like. Menachem Kasher’s Haggadah Sheleimah, an encyclopedic work (like his Torah Sheleimah), is as much a reference work as a useful haggadah to have at the seder table. You want variants of the Kadesh Urchatz mnemonic? Here they are, about a dozen of them. A synoptic version of the Arami Oved Avi? Yes. What about essays on various halachic and ideologic problems in the haggadah? Sure. Catalogs of different charosets in the rabbinic foundational texts? Enjoy! Through it all, Kasher is present. He does not refer to himself in the first person, but he has his biases, preferences, and pet peeves.

So I was particularly pleased to receive Gabriel Wasserman’s haggadah, called Ashira va’Ashanenna Ba’Chashikot, a work he has assiduously updated over the past few years. I bought the sefer fair and square, and you should get it too (available from the author by email, gavrielwasserman@gmail.com). I am relatively knowledgeable in Jewish matters, but I learned a passel of new facts from nearly every page. If I am in the right crowd, I will be hard-pressed not to lift my eyes from the haggadah and say, “Hey! Did you know…” every few pages. Did you know that some communities *do* make a bracha at Urchatz? Or that pears are a common ingredient in many charosets? Did you know that there is no stage of the seder called “Nirtzah”?

Thus this sefer is packed full of chochma (wisdom). What makes it entertaining, though, is Wasserman’s idiosyncratic authorship. What else would you expect from a haggadah with the author’s picture on the front and back? (Though, to be charitable, the front picture is of the back of his head…) Wasserman’s asides refer to friends he has learned from, niggunim he grew up with, recipes he traditionally prepares for the holiday (oh, yes, there are recipes too). There is a running commentary, parallel columns in English and Hebrew (except for the spots where one language seems to leave off for a page). Here too are his own bravura piyyutim. My favorite parts, besides those mentioned, were the mentions of Yemenite practices (all new to me), and the musical notations in the back.

I would love to see this haggadah get broader distribution, so I will allow myself some suggestions. A higher production value, such as might be provided by a mainstream house, might enable illustrations, consistency in layout, and a larger font size for the Hebrew. (Perhaps younger folk than this legally-blind forty-year-old might not have a problem.) The haggadah is not for everyone: the author, it is clear, does not see teaching the children as the primary or even (apparently) the most interesting commandment of the day, though he certainly does not ignore it either. The English translations are occasionally not as eloquent as the author’s Hebrew.

These are minor quibbles in a fascinating, unique, and enlightening work. May Gabriel Wasserman merit many more years of disseminating his piyyutim, Torah, and haggadic spirit to all and sundry!


Key Medical Reversals, 2001-2010
from Prasad et al., Mayo Clinic Proceedings, August 2013 (http://www.mayoclinicproceedings.org/article/PIIS0025619613004059/fulltext)
Englishified by your host

Number 1 (because all 10 can’t fit in one status)

Treating bacteria in the urine in diabetic women without symptoms of urinary infection: DOES NOT HELP

Harding et al., 2002 (http://www.nejm.org/doi/full/10.1056/NEJMoa021042):
In contrast to European groups, many American societies recommended using antibiotics to treat such women. This randomized trial found increased antibiotic use associated with such a practice but without any improvement in complications or reduction in the time of symptomatic infection.

Take-home: Antibiotics don’t help in women without urinary infection symptoms, even if their urine test shows bacteria.

I am looking forward to participating in a TEDMED Google+ Hangout, March 25th at noon, on the topic of Health Myths. You should come participate! To quote a blogpost from the TEDMED folks:

You can get the flu – or worse — from a vaccine. Only old folks get strokes and heart attacks. Calories in, calories out. X-rays cause cancer. Sleep eight hours a night and drink eight glasses of water a day. Skip the sunscreen on a cloudy day. Take a multivitamin every day, just to be on the safe side. An apple a day keeps the doctor away. Exercise more to lose weight.

What are the most popular health myths, and how do they spread?  Does social media spread scams faster that it helps dispel them?  How can doctors help patients practice proven steps for prevention – and still keep up on current research themselves?

Great questions all. Leaving aside a quibble about X-rays and cancer (about which the jury seems to be out still, or at least conflicted), the list above points to something important about so-called health myths: they come in many different flavors. Flu is not caused by a vaccine; that’s just wrong. But older people are generally speaking indeed at higher risk of strokes and heart attacks (though of course it’s not only them). “Exercise more to lose weight” isn’t exactly true, but exercising is one way to keep off weight lost through reduced caloric intake (and – can lead to weight loss by itself, actually).

All this is just to say that one myth may be quite unlike another. They are as diverse in their way as any kind of belief. Thinking more about it, I would like to jettison the whole term “myth” altogether. We all have beliefs. Some of them hew fairly closely to the science – others don’t.

What the summary above artfully avoids is potentially the most interesting question: who believes most in scientifically unfounded assertions? Is it patients, or doctors (and nurses) themselves? I would wager that we are all in the same boat. Much as doctors don’t know statistics, much of us don’t practice according to the medical evidence either.

If you push a little bit on many medical assertions once held to be widely agreed-upon truths, you will find yourself coming away with a handful of dust — and more, if you push harder. Does everyone need screening for prostate cancer? No. What about breast cancer? Unclear. Does vitamin D help much, say, for heart disease (except in older populations at risk of fracture)? Maybe, though the evidence is thin. If we treat mild hypertension, can we expect mortality benefits? Doesn’t seem that way. Yet practices based on these suppositions persist.

In other words, doctors are as much myth-makers, and myth-peddlers, as patients. Which means we all need to reevaluate our relationship to science. If doctors can be as uncertain as patients, shouldn’t we be skeptical of the hierarchy that still obtains in certain quarters? Shouldn’t we come together to discuss our fears, preconceptions, worries, and expectations?

A guest post by a friend who wishes to remain anonymous.

I am an American expat. As a pregnant woman in Israel it is challenging to navigate a new health system when most of my information resources are geared to another system. This is especially true for pregnancy, where there are many decisions to make regarding symptom management, prenatal testing, and giving birth. However, on comparing the US and Israeli health care systems from my perspective, I find that the latter has notable advantages.week34

Unlike the semi-private system in the US, Israel has a nationalized, single-payer health system. This difference reveals itself in terms of spending priorities. For example, in the US, obstetricians are responsible for all prenatal care and deliveries, both low- and high-risk. In Israel, the default is for gynecologists to manage pregnant women’s health and for registered nurse midwives to deliver babies. Special facilities and obstetricians are available in the event of complications. This approach is less costly, yet results in similar or better health outcomes.

In a private system, doctors and hospitals may try to attract patients with perks such as more attractive facilities and more attentive staff. In Israel, the law prohibits private midwives; many hospitals will not accept private OBs or doulas in order to ensure that care is not stratified by economic status. Furthermore, the women I’ve spoken with report somewhat spartan conditions in the regular birth wards, but are overwhelmingly satisfied with the level of care for women and neonates who experience complications. In other words, money goes towards medical necessities rather than pleasing the patients.

Another major difference between the US and Israel is the attitude of medical professionals towards the women in their care. US practitioners are more proactive in providing guidelines to pregnant women regarding food and medication safety and symptom management. Israeli practitioners rely on women to do their own basic research and to ask specific questions. Further, in the Israeli system, women have unlimited, no-cost visits to family doctors and gynecologists, whereas cost of prenatal care and testing are greater concerns to women in the US.

Critics of nationalized health care in the US argue that such systems reduce patient choice and reduce quality of care. In my experience, it is true that patient options are more limited. However, outcomes are comparable on average. Furthermore, the limited out-of-pocket expenses and the clear information on costs faced by patients contribute to peace of mind.

Here are some poems to read if you are too far away to get shalekhmones from me. Or if you don’t celebrate Purim at all…these poems are still for you.


Purim Doggerel 2014

I covered one of the chief residents in our hospital for two days this past week, seeing more than 40 patients in total. My off-the-cuff remarks on Facebook still apply:

Twenty-two inpatients later, it is time once again to declare my awe and admiration for all who do this work daily: hospitalists, housestaff, nurses, techs, custodial staff (et al., et al.). And, of course, the patients who are – on the other side of the hospital mirror – working harder, in their way, than all of us.

What’s more, I was struck – not for the first time – by the differences between the hospital and clinic, not just in tone, atmosphere, communication, and pace, but in how those things affect medical thinking and decision making.

I am not talking about critical care or emergency medicine, nor about “codes” (cardiac resuscitation) – merely because I do not participate in such care regularly. But I think my observations might still apply.

Simply put, the hospital operates under the assumption that things have to move faster. That tempo, I believe, encourages a certain frame of mind: we should treat, do, test. People are sick, we want to make them better, and lab tests and interventions are an avenue to this.

You already see where I’m going, because – if you know me or my blog – you know my bias. If anything, I think we tend to over-order as a health care system….and the scientific literature bears me out.

What would it mean to apply evidence-based medicine to hospital care, in a thorough-going fashion? I mostly do outpatient medicine, and guarantee you that I assume no superiority for the application of EBM in that realm: no, much of what we do in clinic is still based on intuition, externalities, unsupported lore, personal preference (not the patient’s, God forbid, but our own as doctors), or some other blend of bias and conviction.

Would it be harder in the hospital to take stock? Would workflow be disrupted?

Or is it just that I am unaccustomed to the hospital, and things are really changing in that direction? What do you think?

Noncompliance means I think the patient should do it this way and the patient didn’t do it this way.

“Noncompliance” makes no effort to figure out why the patient did what they did, or what alternatives they might have selected instead.

“Noncompliance’ makes no effort to figure out if the alternative suggested (or: mandated) by the doctor was the best of all possible alternatives in the first place.

The noncompliant patient is by definition not a team player. Not the sort of patient you want to be – or the sort of patient you want to treat (if you are a provider).

“Noncompliance” is never good.

Can we get rid, once and for all, of “noncompliance”?

Can we talk about what people do and why they do it?

Can we quit assuming that doctors know better?

Can we advise and let patients choose?

Still waiting.

My Facebook feed is riven in two. On the one hand, there are free-thinking, scientistic doctors, patients, and those who love them (or tolerate them enough not to hide their status updates). On the other, are Jews: and, for some reason having to do with personal curiosity and involvement with Yiddish speakers, many of them are Jews who are Chasidic, used to be, or are somewhere in between.

Both camps are in the throes of realignment. The former, because evidence-based medicine is screeching towards the end of a game of chicken, the other competitor being (unfortunately) the patient as a person, with power over her own decision making.

Let’s take the most recent example of this hair-raising collision: statins. Cholesterol medicines, in other words, and what to do about them. Yes, we should probably get rid of these artificial numerical targets, it seems like most people agree on that. But the new guidelines, according to which (grosso modo) everyone with an estimate 10-year heart disease risk of 7.5% “needs” to be on such a medication, are rightfully controversial. If you are the type to read JAMA articles, you will be entertained by John Ioannidis (he of the “half of all scientific findings are wrong”) on the one hand, who darkly prophesies “one of the worst disasters in medical history” due to vast overtreatment with statins. (Um. Flu? AIDS? The plague?), and, on the other hand, a professional, prudent take by some collaborators on the new guidelines themselves, who take what seems to be the best defense possible: The science is better; we are working towards incremental improvement of guidelines. In short: nothing’s perfect. This is a step forward from where we were.

If you read the articles back-to-back, it seems an awful lot like the internal breakup currently convulsing ultra-Orthodoxy. Belief and practice are at loggerheads, and tiny fish are getting squished between the logs. Are you a believer or not? Are you an incremental advancer or a revolutionary? Are you willing to listen to doctors by virtue of their social standing and hereditary place as healers, even if their advice might not be better than random chance?

Does medicine need a revolution to upend received wisdom – even the new received wisdom of our day, which is the dogma of evidence-based medicine – enthroning in its place the empowered singular patient? Sure, if you are the type to upend and revolt. But not even the most engaged of patients want to get rid of everything the medical establishment has to offer. Similarly, even those about to leave their hidebound religious communities sometimes find themselves at peace with a stable compromise. They don’t have to believe in everything.

If a revolution is possible, but we choose an incremental change, are we being sensible – or hypocritical?

I am doing some research for a book I am writing – more details anon, at least if it gets written, finds favor in the eyes of my agent, and turns into a bound-and-published butterfly. Some of the resources I needed were only available in the stacks of the Johns Hopkins medical library. To their credit, rather than turning the huge, high-ceilinged bibliotemple into yet another office complex, or tearing it down for laboratory space, the librarians – sorry, informationists – asked the users what they wanted. “Let’s keep the library,” said the users, “but renovate it.”

I use the library an awful lot, mostly as a route to borrow resources from other libraries (often on medical themes but just as often on Jewish topics, which probably confuses somebody). Usually, the library brings books directly to my office, which for me is the equivalent of lying on a couch in my toga being fed peeled grapes. The delivery guy is as reliable as the mythical appointed couriers of the Post Office, making it to my office with snow-covered boots and a plastic bag full of library holdings.

Last week, I got an email that a book I had requested was already available, so I would not get it delivered. “See Notes,” said the email, and then, on the line below: “See stacks.”

Stacks! I had never ventured into the Welch Library stacks. In previous stages of my career and years of school, I had always spent time among the books when I least needed to. I found it a refuge. When everything is supposedly available at your fingertips, sometimes you need to be lured into a space where you find by serendipity, not by search. But here, I have not made the time, or, more likely, not allowed myself the luxury of wasted time.

A friendly staff person showed me the way: “Go down that hallway. Take the elevator.” Then she flitted away as if she had divulged a secret to me and was worried she might be found out. The elevator was a rickety thing, a banged-up box set on a shaft: “Be kind to the next user and close the gate AND the door!” The inspection certificate, defying my expectations, was up to date.

I found the book I wanted, but the quiet was an added gift: a surround sound version of that stillness found in a conservatory, a botanic garden, a chapel. I browsed a set of an Italian biology journal: glossy pages, full-color illustrations, the work of generations of scientists I would never know and never read.

The variety was luxuriant, rich, and ignored, a buried garden inside the very walls of biomedicine’s fortress. When would the voice of the granting authority find me and cast me out? Where was the flaming sword to guard against intruders?

The security guard smiled on my way out. “Did you find what you needed?”

I nodded, showing her what I could from my brief voyage: a bound book.

Last week I was invited to talk at the DC offices of One Medical Group, which was a healthcare startup back in 2009 when I finished residency (I interviewed with them for a job, as a matter of fact). Now it’s a going concern, with branches in San Francisco, New York, and DC — and, now that I look at their web site, in Chicago, Boston, and LA, as well. One of my friends from residency, Will Kimbrough, is the medical director of the DC office. He is an incredibly smart guy, consummately professional, innately humble, and not afraid to call out bullshit: powerful virtues make for a clinical leader and builder.

Nevertheless, before I knew Will was working there (and, to be honest, maybe for a bit after) I had my assumptions about One Medical Group – because it practices concierge medicine. Concierge medicine is for rich people, I thought. “Thought” is maybe a strong term: it was my assumption, born of ignorance and lack of acquaintance with such a model.

I can’t say that I am now intimately acquainted with a concierge model after an afternoon at One Medical Group. But I had a good time giving a short talk to a group of energetic, young doctors who told anecdotes about patients that sound an awful lot like mine. I still wouldn’t rely on the concierge system to fix our American health care holes, but it might indeed be a reasonable way of providing care to those that can afford it. And, who knows, maybe the price and quality transparency that have long been a natural, unquestioned characteristic of markets for other goods – cars, groceries – might make its way into the health care market in part through such private companies.

* * *

Sean Looney was a high school friend of mine, a tall guy who was often smiling. Our group of nerds thought we were hot shit (in a quiz-bowl, socially awkward sort of way), but he alone among us seemed to realize that it was worth our while to try and act like normal people, even though we were more academically oriented than others. Or, at least, not to be irremediably dorky.1045090_10151929081984001_1913062913_n

After getting a liberal arts degree, he went back to medical school and completed a family practice residency in Cheyenne, Wyoming; he told me about an instructor who could tell the caliber of a bullet by the sound it made falling into a metal bedpan. He then practiced medicine in many places across the country, but in these last years in Pikeville (county seat of Pike County, Kentucky), and in Louisville. He got married.

We weren’t really in close touch since high school, and I couldn’t make it to his wedding. But I did remember the kind of patients he said he took care of in Louisville: alcoholics with schizophrenia. Problems that are not, to be honest, on the pages of the New England Journal too often, and not the subject of fancy clinical trials.

Sean died suddenly last week at the age of 40. His close friends, wife, and family are heartbroken. When I called his mom, I tried to tell her that he is, and was, an inspiration to me.

Sean’s sympathy for people was informed by a love of literature. Sean, me, and our mutual friend Jon (who I have known for a long time, even longer than Sean) used to quote El Cid and Spanish romances to each other. He freely cited musicals and I remember he loved opera.

A healing art needs humaneness, a fertile mind and heart, like those Sean had.

* * *

Like concierge medicine, we can’t build our entire health care system on the safety net, but we want such humaneness for people of all strata.