Rheum in Bloom

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Editor’s note: This is Dr. Chan’s last post for her “Rheum in Bloom” column. She is saying goodbye to New England, leaving the private practice setting for a different challenge.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.

–Sandeep Jauhar, MD

For as long as I’ve been a doctor, doctors have lamented how much medicine has changed. Columnist Charles Krauthammer, MD, wrote a widely-circulated piece in 2015 with the catchy title “Why Doctors Quit,” attributing physician dissatisfaction to the wasteful and frustrating electronic health record mandate. It is worth noting here that Dr. Krauthammer is a political partisan making a point about government overreach and not really about the state of medicine, but the piece certainly resonated with doctors, judging by the number of times it was shared with me. In Medscape’s physician compensation poll of 2016, only 64% of doctors would choose medicine again. In a separate Medscape poll on burnout, under 30% of physicians felt happy at work.

In Dr. Sandeep Jauhar’s book, “Doctored,” (from which the above quote is taken), he cites several issues: the lack of respect that the profession is afforded, the practice of defensive medicine, inadequate compensation, the lack of independence. He goes further: “... Surveys have shown that 30%-40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.” He does not say where he got that information, but it sounds plausible.

I asked peers, mostly people I went through training with and therefore generally belonging to my age group. This small, nonrepresentative sample of young physician parents, many of whom are foreign graduates, seemed to belie Dr. Jauhar’s pessimism. Most of my friends thought medicine is still rewarding. They see our profession as emotionally meaningful and intellectually fulfilling – this despite a surprising number of them having been named in ultimately unsuccessful lawsuits. “The headaches are many, but most professions that make decent money have their own set of headaches and problems,” my allergist friend says. In addition, a career in medicine, they feel, would provide their children financial stability. The consensus was that if their children wanted to, my peers would be nothing but supportive.

I asked my boss about it, too. He is older and very vocal about what he perceives as a hostile working environment. If there was just one demographic that Dr. Krauthammer was speaking for, that is exactly the demographic that my boss belongs to. So I was certain that he had similarly dissuaded his son from going into medicine. But I was wrong.

It isn’t that my boss discouraged his son; it’s that his son was not interested. He says if he thought his son might have enjoyed the work he absolutely would have encouraged it. Because as onerous as our profession has become, it is still a meaningful and rewarding one. And as long as we derive meaning from the work that we do, it is much easier to put up with the unsavory parts.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I was in London for the just-concluded EULAR congress. Oh, the United Kingdom, that bastion of socialist medicine, where the National Health Service is the great equalizer. Heaven sent to some, death spiral of long wait times and old-fashioned medicine to others. While there, I chatted with people who have had experience with the NHS.

I spoke with a health care consultant, whose job is to make hospitals less wasteful. He says the U.K.’s health care expenditure as a percent of GDP [gross domestic product] is too high, compared with other Western nations. I suspect this was a line that he probably heard somewhere and blindly repeated, because when I pressed, he could not tell me what the numbers were, nor could he name the countries he was referring to.

I asked him for examples of how he thought the hospitals he’d served might save money. His biggest complaint was that many patients stay in hospital for months not out of medical necessity but because there is no system in place for lower-level care.

Another friend is the director of a home care service just outside Central London. She tells me that patients have access to an extraordinary amount of resources that allows them to stay at home: suction machines, dialysis machines, home aides. This is great for patients, but she is astounded by how many people got services that she thought were undeserved.

She also told me that, apropos of the impending Brexit, many of their home health aides come from other Eurozone countries. The British do not want to do these jobs, so should the Brexit happen, home health aides will be much harder to come by.

Of course, the most common complaint I heard was that wait times to see a physician are ridiculous. Those who can afford it, can get private insurance, which would allow them access to physicians sooner. In fact, private insurance is often an incentive for people to get promoted.

The British think their health care system is wasteful, as we do for ours. But according to the World Bank’s data from 2014, their health care spending as a percent of GDP is 9.1%, which is much better than ours at 17.1%. And although I was told by the health care consultant that their figure is higher than their neighbors, that just isn’t true. France’s figure is 11.5%, Belgium’s 10.6%, and Spain’s 9.0%. So what I took away from it was this: As different as our health care systems are, they are problematic in the same ways. People have health care that works. But hospital stays are often unnecessary, people take advantage of social safety nets, and there are jobs that mostly only immigrants are willing to perform. Wealthy people can afford to pay for private insurance. And the wait times! People will always complain about wait times, just like they do here, and elsewhere.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I was in London for the just-concluded EULAR congress. Oh, the United Kingdom, that bastion of socialist medicine, where the National Health Service is the great equalizer. Heaven sent to some, death spiral of long wait times and old-fashioned medicine to others. While there, I chatted with people who have had experience with the NHS.

I spoke with a health care consultant, whose job is to make hospitals less wasteful. He says the U.K.’s health care expenditure as a percent of GDP [gross domestic product] is too high, compared with other Western nations. I suspect this was a line that he probably heard somewhere and blindly repeated, because when I pressed, he could not tell me what the numbers were, nor could he name the countries he was referring to.

I asked him for examples of how he thought the hospitals he’d served might save money. His biggest complaint was that many patients stay in hospital for months not out of medical necessity but because there is no system in place for lower-level care.

Another friend is the director of a home care service just outside Central London. She tells me that patients have access to an extraordinary amount of resources that allows them to stay at home: suction machines, dialysis machines, home aides. This is great for patients, but she is astounded by how many people got services that she thought were undeserved.

She also told me that, apropos of the impending Brexit, many of their home health aides come from other Eurozone countries. The British do not want to do these jobs, so should the Brexit happen, home health aides will be much harder to come by.

Of course, the most common complaint I heard was that wait times to see a physician are ridiculous. Those who can afford it, can get private insurance, which would allow them access to physicians sooner. In fact, private insurance is often an incentive for people to get promoted.

The British think their health care system is wasteful, as we do for ours. But according to the World Bank’s data from 2014, their health care spending as a percent of GDP is 9.1%, which is much better than ours at 17.1%. And although I was told by the health care consultant that their figure is higher than their neighbors, that just isn’t true. France’s figure is 11.5%, Belgium’s 10.6%, and Spain’s 9.0%. So what I took away from it was this: As different as our health care systems are, they are problematic in the same ways. People have health care that works. But hospital stays are often unnecessary, people take advantage of social safety nets, and there are jobs that mostly only immigrants are willing to perform. Wealthy people can afford to pay for private insurance. And the wait times! People will always complain about wait times, just like they do here, and elsewhere.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I was in London for the just-concluded EULAR congress. Oh, the United Kingdom, that bastion of socialist medicine, where the National Health Service is the great equalizer. Heaven sent to some, death spiral of long wait times and old-fashioned medicine to others. While there, I chatted with people who have had experience with the NHS.

I spoke with a health care consultant, whose job is to make hospitals less wasteful. He says the U.K.’s health care expenditure as a percent of GDP [gross domestic product] is too high, compared with other Western nations. I suspect this was a line that he probably heard somewhere and blindly repeated, because when I pressed, he could not tell me what the numbers were, nor could he name the countries he was referring to.

I asked him for examples of how he thought the hospitals he’d served might save money. His biggest complaint was that many patients stay in hospital for months not out of medical necessity but because there is no system in place for lower-level care.

Another friend is the director of a home care service just outside Central London. She tells me that patients have access to an extraordinary amount of resources that allows them to stay at home: suction machines, dialysis machines, home aides. This is great for patients, but she is astounded by how many people got services that she thought were undeserved.

She also told me that, apropos of the impending Brexit, many of their home health aides come from other Eurozone countries. The British do not want to do these jobs, so should the Brexit happen, home health aides will be much harder to come by.

Of course, the most common complaint I heard was that wait times to see a physician are ridiculous. Those who can afford it, can get private insurance, which would allow them access to physicians sooner. In fact, private insurance is often an incentive for people to get promoted.

The British think their health care system is wasteful, as we do for ours. But according to the World Bank’s data from 2014, their health care spending as a percent of GDP is 9.1%, which is much better than ours at 17.1%. And although I was told by the health care consultant that their figure is higher than their neighbors, that just isn’t true. France’s figure is 11.5%, Belgium’s 10.6%, and Spain’s 9.0%. So what I took away from it was this: As different as our health care systems are, they are problematic in the same ways. People have health care that works. But hospital stays are often unnecessary, people take advantage of social safety nets, and there are jobs that mostly only immigrants are willing to perform. Wealthy people can afford to pay for private insurance. And the wait times! People will always complain about wait times, just like they do here, and elsewhere.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My newest iteration of a VIP, or very ill patient, is a lovely middle-aged gentleman who has been sick for a year with a multisystem disorder. It started with severely swollen hands and feet along with significant anemia and fatigue. One year, many imaging studies, a couple of biopsies, and a latent tuberculosis infection later, he is still very sick. Throughout his ordeal he has often said to me: “You are the quarterback.” I’ve taken that to heart.

I don’t know why this surprises me, but insurance companies are being increasingly difficult. They’re passing more of the cost of health care to patients, and they’re less willing to cover medications and procedures. I have patients who can’t get physical therapy because they can’t afford the $45 copay for each visit. One patient stopped her hydroxychloroquine because it went from $4/month to $90/month. A couple of patients have opted not to take risedronate because the copay per month is $200 – that’s $200 for one generic pill.

At a recent morbidity and mortality conference, the attendees, nonrheumatologists all, were incredulous that cyclophosphamide, which has been around for ages and should be generic, is not covered by Medicare. Our patient with granulomatosis with polyangiitis and alveolar hemorrhage was on the hook for several hundred dollars per month, which he couldn’t afford.

Insurers also have been giving me more pushback for medications. For example, I recently tried to start one of my patients on etanercept for rheumatoid arthritis. His insurance company wrote to say etanercept was not their “preferred” first-line biologic. I explained that their preferred anti-TNF agents all carried the potential for developing anti-drug antibodies when used without methotrexate, which was contraindicated in my patient. They were unmoved.

I had a similar experience with my VIP. He was denied tocilizumab because he had not yet tried and failed two anti-TNF agents. I appealed the decision because I thought etanercept had caused a side effect that might be a class effect. To my surprise, rather than getting an approval, I received instead a request for medical literature to support my theory. Who knew that the decision-bots were so sophisticated?

Ultimately, I got the drug approved, but of course this process was an inconvenience to me, adding unnecessarily to the work of doctoring. More importantly, it was time wasted for my patient who was suffering tremendously.

My point is this: The idea of me as quarterback is quaint. Ultimately, it is the insurance company that dictates testing, treatment, physician, and facility.

There is an expectation that physicians are perfect, and we have internalized that expectation to some degree, holding ourselves to exacting standards, guided by what’s in the patient’s best interest. I want to know what sort of standards insurance companies hold themselves to, because I think they – out of all of us involved in health care – they who have the greatest resources should be absolutely unimpeachable.

Dr. Chan practices rheumatology in Pawtucket, R.I.

The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.

One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.

Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?

On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.

Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.

If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.

Dr. Chan practices rheumatology in Pawtucket, R.I.

The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.

One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.

Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?

On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.

Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.

If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.

Dr. Chan practices rheumatology in Pawtucket, R.I.

The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.

One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.

Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?

On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.

Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.

If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.

Dr. Chan practices rheumatology in Pawtucket, R.I.

There has been a lot of publicity surrounding the increasing use of prescription painkillers and subsequent increase in deaths. In 2014, there were close to 19,000 deaths related to opioid painkiller overdose. State and federal governments have reacted with various initiatives, from changing the scheduling of Vicodin, to initiating prescription drug–monitoring programs, to limiting the number of pills dispensed. There are loud voices on either side of this debate, to be sure, but perhaps none so aggravating as the aggravated patient.

I did not start my practice with any prescribing “policy,” as I thought such policies were arbitrary. I am a physician, after all, so why wouldn’t I prescribe a narcotic if necessary? I also trained at a time when pain was considered “the fifth vital sign,” and we were taught to treat it aggressively.

But after a while you learn that trust in patients can be misplaced. You never forget the first nice lady whose urine drug screen comes back negative when you expected it to show the narcotic that you were prescribing her. You never forget the person who calls on a weekend claiming to be a patient of the practice and turns out not to be. And when your colleague gets her DEA number stolen and her signature forged, you finally learn that humanity is imperfect. What’s more, in your transition from young naive doctor to elder statesman, you learn that the push to treat pain so aggressively was achieved, in large part, by lobbying from the pharmaceutical industry.

Some patients of course can have a legitimate need for narcotics and truly derive benefit from them. In such patients, it is our practice to have the patient sign a pain “contract.” Such contracts are nonbinding, but give the narcotic prescription the gravitas that it deserves, underscoring the sacrosanct nature not just of the prescription but also of the physician-patient relationship. They specify the strength of the prescription, the number of pills dispensed, the pharmacy at which the prescription is to be filled, and the physician’s prerogative to do random drug screens.

The more vexing problem for rheumatologists involves patients with central sensitization and chronic pain. These patients seem predisposed to requiring escalating doses of narcotics, and they often have risk factors for developing narcotic abuse disorders. In addition, there is no evidence that chronic narcotic use provides any long-term benefit. But it is a rare chronic pain patient who is willing to accept that narcotics are not the answer to his or her problems.

One way to manage this is for the patients to not be given narcotics in the first place. That probably requires lobbying of a different kind: educating primary care providers and emergency department physicians on how to recognize chronic pain or central sensitization syndromes and disseminating the literature showing that narcotics have no long-term benefit in such cases.

Dr. Chan practices rheumatology in Pawtucket, R.I.

There has been a lot of publicity surrounding the increasing use of prescription painkillers and subsequent increase in deaths. In 2014, there were close to 19,000 deaths related to opioid painkiller overdose. State and federal governments have reacted with various initiatives, from changing the scheduling of Vicodin, to initiating prescription drug–monitoring programs, to limiting the number of pills dispensed. There are loud voices on either side of this debate, to be sure, but perhaps none so aggravating as the aggravated patient.

I did not start my practice with any prescribing “policy,” as I thought such policies were arbitrary. I am a physician, after all, so why wouldn’t I prescribe a narcotic if necessary? I also trained at a time when pain was considered “the fifth vital sign,” and we were taught to treat it aggressively.

But after a while you learn that trust in patients can be misplaced. You never forget the first nice lady whose urine drug screen comes back negative when you expected it to show the narcotic that you were prescribing her. You never forget the person who calls on a weekend claiming to be a patient of the practice and turns out not to be. And when your colleague gets her DEA number stolen and her signature forged, you finally learn that humanity is imperfect. What’s more, in your transition from young naive doctor to elder statesman, you learn that the push to treat pain so aggressively was achieved, in large part, by lobbying from the pharmaceutical industry.

Some patients of course can have a legitimate need for narcotics and truly derive benefit from them. In such patients, it is our practice to have the patient sign a pain “contract.” Such contracts are nonbinding, but give the narcotic prescription the gravitas that it deserves, underscoring the sacrosanct nature not just of the prescription but also of the physician-patient relationship. They specify the strength of the prescription, the number of pills dispensed, the pharmacy at which the prescription is to be filled, and the physician’s prerogative to do random drug screens.

The more vexing problem for rheumatologists involves patients with central sensitization and chronic pain. These patients seem predisposed to requiring escalating doses of narcotics, and they often have risk factors for developing narcotic abuse disorders. In addition, there is no evidence that chronic narcotic use provides any long-term benefit. But it is a rare chronic pain patient who is willing to accept that narcotics are not the answer to his or her problems.

One way to manage this is for the patients to not be given narcotics in the first place. That probably requires lobbying of a different kind: educating primary care providers and emergency department physicians on how to recognize chronic pain or central sensitization syndromes and disseminating the literature showing that narcotics have no long-term benefit in such cases.

Dr. Chan practices rheumatology in Pawtucket, R.I.

There has been a lot of publicity surrounding the increasing use of prescription painkillers and subsequent increase in deaths. In 2014, there were close to 19,000 deaths related to opioid painkiller overdose. State and federal governments have reacted with various initiatives, from changing the scheduling of Vicodin, to initiating prescription drug–monitoring programs, to limiting the number of pills dispensed. There are loud voices on either side of this debate, to be sure, but perhaps none so aggravating as the aggravated patient.

I did not start my practice with any prescribing “policy,” as I thought such policies were arbitrary. I am a physician, after all, so why wouldn’t I prescribe a narcotic if necessary? I also trained at a time when pain was considered “the fifth vital sign,” and we were taught to treat it aggressively.

But after a while you learn that trust in patients can be misplaced. You never forget the first nice lady whose urine drug screen comes back negative when you expected it to show the narcotic that you were prescribing her. You never forget the person who calls on a weekend claiming to be a patient of the practice and turns out not to be. And when your colleague gets her DEA number stolen and her signature forged, you finally learn that humanity is imperfect. What’s more, in your transition from young naive doctor to elder statesman, you learn that the push to treat pain so aggressively was achieved, in large part, by lobbying from the pharmaceutical industry.

Some patients of course can have a legitimate need for narcotics and truly derive benefit from them. In such patients, it is our practice to have the patient sign a pain “contract.” Such contracts are nonbinding, but give the narcotic prescription the gravitas that it deserves, underscoring the sacrosanct nature not just of the prescription but also of the physician-patient relationship. They specify the strength of the prescription, the number of pills dispensed, the pharmacy at which the prescription is to be filled, and the physician’s prerogative to do random drug screens.

The more vexing problem for rheumatologists involves patients with central sensitization and chronic pain. These patients seem predisposed to requiring escalating doses of narcotics, and they often have risk factors for developing narcotic abuse disorders. In addition, there is no evidence that chronic narcotic use provides any long-term benefit. But it is a rare chronic pain patient who is willing to accept that narcotics are not the answer to his or her problems.

One way to manage this is for the patients to not be given narcotics in the first place. That probably requires lobbying of a different kind: educating primary care providers and emergency department physicians on how to recognize chronic pain or central sensitization syndromes and disseminating the literature showing that narcotics have no long-term benefit in such cases.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly”

—Søren Kierkegaard

In our interactions with patients we often focus on the medical issue at hand, forgetting the other dimensions of our patients’ lives. Yet these invisible dimensions can have a huge impact on their humanity. I humbly submit that it can be profoundly meaningful, for them and for us, if we paid close attention.

1. JV has rheumatoid arthritis. He is not the most compliant, and I had not seen him in over a year. He was well controlled on Enbrel.

He came to the office one day last week to make an appointment. We gave him one for the next day, but he missed the appointment. When he finally came a week later, I got the real story. He had gotten arrested.

The day he came into my office to ask for an appointment after a prolonged absence, it was because his insurance was denying coverage for his Enbrel. His next stop, after making his appointment, was to the Social Security office to try to sort out his coverage. When asked about whether or not he needed special accommodations, he made a point to mention his hearing loss. However, the person ultimately assigned to help him was not a native English speaker. This made for a very confusing and loud exchange that led to a heated argument with security. It ended with him being led out of the office in handcuffs, and spending the night in jail.

2. Tyler has inflammatory arthritis. He received his diagnosis in Arizona 5 years ago. He was stable on Plaquenil when I met him a year ago, and I only see him every 6 months.

On our third visit, I noticed he had gained weight. He attributed this to the discontinuation of his Dexedrine, in the interest of adjusting his medications for bipolar disorder. I couldn’t remember our second visit very well, but he apologized profusely for having been “lit.” He apparently was so manic that it drove his family crazy. In an effort to get him to take medications for the problem, his sister said: “It’s like living with Vincent van Gogh, except now we have meds for it.”

Now he takes his medications. As a result, his body feels foreign. In the summer, he ran around the backyard all day and night constructing an obstacle course for his dog that he knew he would never get right. Now he is lucky if he gets a few days a week of productive work on his art. He feels dulled; he is not as quick-witted. It is sad, but, he says, this is what society expects of him.

3. Judy is in her mid-70s. That’s not old these days, but she is somewhat crippled by her rheumatoid arthritis. She lived in Manhattan with her husband and enjoyed the city immensely. After her husband passed away, she managed to live in her Manhattan apartment independently for a little bit, but after suffering a fall, she let her children move her to Rhode Island to be closer to them. She has struggled to find her own apartment with amenities that will allow her to remain independent. For the past 3 years she has been in an assisted living facility.

She is so unhappy there. She doesn’t like forced interactions, doesn’t like to gossip, doesn’t like when her neighbors behave like they’re in middle school. It has taken 3 years for the people around her to finally respect her desire to be left alone, to spend her time reading and listening to the opera rather than engaging in idle chitchat that does not interest her at all.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly”

—Søren Kierkegaard

In our interactions with patients we often focus on the medical issue at hand, forgetting the other dimensions of our patients’ lives. Yet these invisible dimensions can have a huge impact on their humanity. I humbly submit that it can be profoundly meaningful, for them and for us, if we paid close attention.

1. JV has rheumatoid arthritis. He is not the most compliant, and I had not seen him in over a year. He was well controlled on Enbrel.

He came to the office one day last week to make an appointment. We gave him one for the next day, but he missed the appointment. When he finally came a week later, I got the real story. He had gotten arrested.

The day he came into my office to ask for an appointment after a prolonged absence, it was because his insurance was denying coverage for his Enbrel. His next stop, after making his appointment, was to the Social Security office to try to sort out his coverage. When asked about whether or not he needed special accommodations, he made a point to mention his hearing loss. However, the person ultimately assigned to help him was not a native English speaker. This made for a very confusing and loud exchange that led to a heated argument with security. It ended with him being led out of the office in handcuffs, and spending the night in jail.

2. Tyler has inflammatory arthritis. He received his diagnosis in Arizona 5 years ago. He was stable on Plaquenil when I met him a year ago, and I only see him every 6 months.

On our third visit, I noticed he had gained weight. He attributed this to the discontinuation of his Dexedrine, in the interest of adjusting his medications for bipolar disorder. I couldn’t remember our second visit very well, but he apologized profusely for having been “lit.” He apparently was so manic that it drove his family crazy. In an effort to get him to take medications for the problem, his sister said: “It’s like living with Vincent van Gogh, except now we have meds for it.”

Now he takes his medications. As a result, his body feels foreign. In the summer, he ran around the backyard all day and night constructing an obstacle course for his dog that he knew he would never get right. Now he is lucky if he gets a few days a week of productive work on his art. He feels dulled; he is not as quick-witted. It is sad, but, he says, this is what society expects of him.

3. Judy is in her mid-70s. That’s not old these days, but she is somewhat crippled by her rheumatoid arthritis. She lived in Manhattan with her husband and enjoyed the city immensely. After her husband passed away, she managed to live in her Manhattan apartment independently for a little bit, but after suffering a fall, she let her children move her to Rhode Island to be closer to them. She has struggled to find her own apartment with amenities that will allow her to remain independent. For the past 3 years she has been in an assisted living facility.

She is so unhappy there. She doesn’t like forced interactions, doesn’t like to gossip, doesn’t like when her neighbors behave like they’re in middle school. It has taken 3 years for the people around her to finally respect her desire to be left alone, to spend her time reading and listening to the opera rather than engaging in idle chitchat that does not interest her at all.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly”

—Søren Kierkegaard

In our interactions with patients we often focus on the medical issue at hand, forgetting the other dimensions of our patients’ lives. Yet these invisible dimensions can have a huge impact on their humanity. I humbly submit that it can be profoundly meaningful, for them and for us, if we paid close attention.

1. JV has rheumatoid arthritis. He is not the most compliant, and I had not seen him in over a year. He was well controlled on Enbrel.

He came to the office one day last week to make an appointment. We gave him one for the next day, but he missed the appointment. When he finally came a week later, I got the real story. He had gotten arrested.

The day he came into my office to ask for an appointment after a prolonged absence, it was because his insurance was denying coverage for his Enbrel. His next stop, after making his appointment, was to the Social Security office to try to sort out his coverage. When asked about whether or not he needed special accommodations, he made a point to mention his hearing loss. However, the person ultimately assigned to help him was not a native English speaker. This made for a very confusing and loud exchange that led to a heated argument with security. It ended with him being led out of the office in handcuffs, and spending the night in jail.

2. Tyler has inflammatory arthritis. He received his diagnosis in Arizona 5 years ago. He was stable on Plaquenil when I met him a year ago, and I only see him every 6 months.

On our third visit, I noticed he had gained weight. He attributed this to the discontinuation of his Dexedrine, in the interest of adjusting his medications for bipolar disorder. I couldn’t remember our second visit very well, but he apologized profusely for having been “lit.” He apparently was so manic that it drove his family crazy. In an effort to get him to take medications for the problem, his sister said: “It’s like living with Vincent van Gogh, except now we have meds for it.”

Now he takes his medications. As a result, his body feels foreign. In the summer, he ran around the backyard all day and night constructing an obstacle course for his dog that he knew he would never get right. Now he is lucky if he gets a few days a week of productive work on his art. He feels dulled; he is not as quick-witted. It is sad, but, he says, this is what society expects of him.

3. Judy is in her mid-70s. That’s not old these days, but she is somewhat crippled by her rheumatoid arthritis. She lived in Manhattan with her husband and enjoyed the city immensely. After her husband passed away, she managed to live in her Manhattan apartment independently for a little bit, but after suffering a fall, she let her children move her to Rhode Island to be closer to them. She has struggled to find her own apartment with amenities that will allow her to remain independent. For the past 3 years she has been in an assisted living facility.

She is so unhappy there. She doesn’t like forced interactions, doesn’t like to gossip, doesn’t like when her neighbors behave like they’re in middle school. It has taken 3 years for the people around her to finally respect her desire to be left alone, to spend her time reading and listening to the opera rather than engaging in idle chitchat that does not interest her at all.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In a letter dated Nov. 20, 2015, a particular insurance company reminded me that I need to think about healthcare costs. I got a breakdown of how often in the quarter I used proprietary vs. generic drugs, how I compared to other rheumatologists, and how I compared to other physicians. I also got a list of the drugs that I used and alternatives that I should be thinking about instead. In principle, this is not a terrible idea. But let me describe some glaring mistakes that show that these letters are in fact a contradiction in themselves. They are a huge waste of resources.

The letter suggested that my number one “prescribed brand drug with potential member savings opportunities” was Uloric, costing an average of $302 per prescription. The suggested “generic” alternative was Colcrys, leading to a “potential annual cost savings” of $600.

Third drug on my list? Colcrys, coming in at $165 per prescription with a potential annual savings of $300. Listed alternative: allopurinol.

We rheumatologists know that Colcrys is not an alternative to Uloric, and allopurinol is not an alternative to Colcrys. Also, suggesting an alternative only to suggest an alternative to that alternative is idiotic. Obviously, the letter is generated by a data-crunching algorithm. But an algorithm can only be as good as the programmer creating it.

As for my other proprietary prescriptions: Lyrica was the second on my list, and Celebrex the fourth. Let me explain why this is both annoying and inefficient. Before I could prescribe those drugs, this insurer made me jump through hoops to get them. In other words, there already exists in their database proof that I had already tried their recommended alternatives.

I can only conclude that within the bowels of health insurance corporate offices, and probably in more places than I care to imagine, there are people who are either incompetent or lazy, or both, making healthcare decisions.

So, to the health insurer: Forgive me if I ignore your reminder. I already know that healthcare costs are bloated. I am already quite conscientious about my prescribing practices. I think I can speak for all rheumatologists who receive these notices: You’re barking up the wrong tree.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“We are just statistics, born to consume resources.” –Horace

You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.

I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).

I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:

“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.

“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”

On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.

“Sildenafil will be approved based on one of the following criteria:

(1) All of the following:

(A) Pulmonary arterial hypertension is symptomatic; AND

(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR

(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”

On Dec. 4, I fired off the following response:

“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”

It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“We are just statistics, born to consume resources.” –Horace

You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.

I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).

I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:

“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.

“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”

On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.

“Sildenafil will be approved based on one of the following criteria:

(1) All of the following:

(A) Pulmonary arterial hypertension is symptomatic; AND

(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR

(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”

On Dec. 4, I fired off the following response:

“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”

It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.

Dr. Chan practices rheumatology in Pawtucket, R.I.

“We are just statistics, born to consume resources.” –Horace

You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.

I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).

I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:

“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.

“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”

On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.

“Sildenafil will be approved based on one of the following criteria:

(1) All of the following:

(A) Pulmonary arterial hypertension is symptomatic; AND

(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR

(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”

On Dec. 4, I fired off the following response:

“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”

It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.