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Do You Dare Visit a Hospital in July?
There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.
We’ve all heard this before. And, frankly, it is annoying.
In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."
I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.
The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.
In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.
New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?
Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.
Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.
We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.
Dr. Chan is in practice in Pawtucket, R.I.
There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.
We’ve all heard this before. And, frankly, it is annoying.
In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."
I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.
The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.
In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.
New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?
Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.
Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.
We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.
Dr. Chan is in practice in Pawtucket, R.I.
There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.
We’ve all heard this before. And, frankly, it is annoying.
In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."
I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.
The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.
In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.
New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?
Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.
Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.
We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.
Dr. Chan is in practice in Pawtucket, R.I.
A Coup for All Americans
When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.
Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)
I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)
Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.
This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.
After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."
Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.
Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.
When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.
Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)
I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)
Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.
This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.
After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."
Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.
Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.
When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.
Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)
I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)
Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.
This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.
After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."
Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.
Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.
Putting a Fine Point to Acupuncture
I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.
Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.
But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.
Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."
With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.
I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.
When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.
I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.
Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.
She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.
At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.
I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.
Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.
I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?
Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].
I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.
Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.
But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.
Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."
With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.
I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.
When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.
I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.
Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.
She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.
At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.
I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.
Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.
I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?
Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].
I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.
Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.
But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.
Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."
With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.
I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.
When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.
I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.
Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.
She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.
At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.
I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.
Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.
I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?
Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].
The Learning Curve
When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.
But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.
I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.
These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.
1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.
2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.
3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).
4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.
5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.
6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.
7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.
8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.
9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.
10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.
11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!
Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.
When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.
But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.
I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.
These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.
1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.
2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.
3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).
4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.
5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.
6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.
7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.
8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.
9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.
10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.
11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!
Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.
When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.
But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.
I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.
These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.
1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.
2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.
3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).
4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.
5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.
6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.
7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.
8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.
9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.
10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.
11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!
Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.