Rheum in Bloom

One of the best parts of my job is meeting people. You can tell a lot by a patient’s name, age, ethnicity, speech, dress, or number and nature of his or her tattoos. But there is a lot more that you won’t know until you have a conversation, and that’s the part that always surprises me. Every interaction offers an opportunity to learn something unexpected about the patient or about oneself.

I recently met a lovely young patient with chronic pain. She had some challenges, including being morbidly obese and on welfare. She had a scar across her left forearm – a deep, well-executed, self-inflicted wound requiring 16 stitches. She’d done it as a teenager and readily admitted that it was a tough time in her life.

But when I got to asking her social history, she lit up with pride. When she was down on her luck some years ago, she decided to learn sign language. She then started a business to incorporate sign language into programs for children with learning disabilities. That left me in awe but also surprised at myself for being so surprised.

And how about a nun who, in addition to having rheumatoid arthritis, also had complex regional pain syndrome after foot surgery. For a year and a half, all she could talk about was how painful her foot was, how miserable she was – so much so that I dreaded each visit, knowing it would make me feel inadequate. I discovered later on that my one-dimensional view of this person as patient was quite limited. “Nun” is not her job description. Her job is with the Social Justice Advocacy arm of her congregation, and most recently her work has focused on interpreting Pope Francis’s encyclical on climate change to make it accessible to congregants. Again, a pleasant surprise.

I was raised Catholic: Heaven and hell, good and evil, Immanuel Kant’s moral imperative. But to be totally postmodern about it, I have a great appreciation for how, unless I walk in another person’s shoes, I will never fully understand them and therefore cannot be the judge of them. In fact, those judgments speak more about me than they do of the patient. What a treat, then, that with each patient interaction I shine a light on my own spirit, and get to know myself a little bit better.

Let me end with a little tribute to Oliver Sacks, who devoted his life to shining a light on the complexities of his patients’ minds: “People will make a life in their own terms, whether they are deaf or colorblind or autistic or whatever. And their world will be quite as rich and interesting and full as our world.”

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

One of the best parts of my job is meeting people. You can tell a lot by a patient’s name, age, ethnicity, speech, dress, or number and nature of his or her tattoos. But there is a lot more that you won’t know until you have a conversation, and that’s the part that always surprises me. Every interaction offers an opportunity to learn something unexpected about the patient or about oneself.

I recently met a lovely young patient with chronic pain. She had some challenges, including being morbidly obese and on welfare. She had a scar across her left forearm – a deep, well-executed, self-inflicted wound requiring 16 stitches. She’d done it as a teenager and readily admitted that it was a tough time in her life.

But when I got to asking her social history, she lit up with pride. When she was down on her luck some years ago, she decided to learn sign language. She then started a business to incorporate sign language into programs for children with learning disabilities. That left me in awe but also surprised at myself for being so surprised.

And how about a nun who, in addition to having rheumatoid arthritis, also had complex regional pain syndrome after foot surgery. For a year and a half, all she could talk about was how painful her foot was, how miserable she was – so much so that I dreaded each visit, knowing it would make me feel inadequate. I discovered later on that my one-dimensional view of this person as patient was quite limited. “Nun” is not her job description. Her job is with the Social Justice Advocacy arm of her congregation, and most recently her work has focused on interpreting Pope Francis’s encyclical on climate change to make it accessible to congregants. Again, a pleasant surprise.

I was raised Catholic: Heaven and hell, good and evil, Immanuel Kant’s moral imperative. But to be totally postmodern about it, I have a great appreciation for how, unless I walk in another person’s shoes, I will never fully understand them and therefore cannot be the judge of them. In fact, those judgments speak more about me than they do of the patient. What a treat, then, that with each patient interaction I shine a light on my own spirit, and get to know myself a little bit better.

Let me end with a little tribute to Oliver Sacks, who devoted his life to shining a light on the complexities of his patients’ minds: “People will make a life in their own terms, whether they are deaf or colorblind or autistic or whatever. And their world will be quite as rich and interesting and full as our world.”

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

One of the best parts of my job is meeting people. You can tell a lot by a patient’s name, age, ethnicity, speech, dress, or number and nature of his or her tattoos. But there is a lot more that you won’t know until you have a conversation, and that’s the part that always surprises me. Every interaction offers an opportunity to learn something unexpected about the patient or about oneself.

I recently met a lovely young patient with chronic pain. She had some challenges, including being morbidly obese and on welfare. She had a scar across her left forearm – a deep, well-executed, self-inflicted wound requiring 16 stitches. She’d done it as a teenager and readily admitted that it was a tough time in her life.

But when I got to asking her social history, she lit up with pride. When she was down on her luck some years ago, she decided to learn sign language. She then started a business to incorporate sign language into programs for children with learning disabilities. That left me in awe but also surprised at myself for being so surprised.

And how about a nun who, in addition to having rheumatoid arthritis, also had complex regional pain syndrome after foot surgery. For a year and a half, all she could talk about was how painful her foot was, how miserable she was – so much so that I dreaded each visit, knowing it would make me feel inadequate. I discovered later on that my one-dimensional view of this person as patient was quite limited. “Nun” is not her job description. Her job is with the Social Justice Advocacy arm of her congregation, and most recently her work has focused on interpreting Pope Francis’s encyclical on climate change to make it accessible to congregants. Again, a pleasant surprise.

I was raised Catholic: Heaven and hell, good and evil, Immanuel Kant’s moral imperative. But to be totally postmodern about it, I have a great appreciation for how, unless I walk in another person’s shoes, I will never fully understand them and therefore cannot be the judge of them. In fact, those judgments speak more about me than they do of the patient. What a treat, then, that with each patient interaction I shine a light on my own spirit, and get to know myself a little bit better.

Let me end with a little tribute to Oliver Sacks, who devoted his life to shining a light on the complexities of his patients’ minds: “People will make a life in their own terms, whether they are deaf or colorblind or autistic or whatever. And their world will be quite as rich and interesting and full as our world.”

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

Some insurance companies recently started sending notifications about patient care. For example, one recently sent my boss a letter about one of his patients with rheumatoid arthritis, asking why the patient is not on a disease modifier. There is an invitation to explain why by ticking any one of several boxes. Is the patient perhaps not compliant? Did the patient discontinue the medication against the doctor’s advice? Has the patient passed away? Does the patient not have rheumatoid arthritis?

Oh, to be a fly on the wall when the insurance company decided that they would start doing this! This must impose a financial burden on the insurer, one that I cannot imagine they take on out of sheer altruism. What is the end game? What do they do with this information? Will they hold this information against the patient somehow, raise their premium in the next enrollment period? Or hold it against the physician, perhaps ding their reimbursement or use the information to include or exclude physicians from their panels?

When I decided to come to the United States, one of the biggest draws was the availability of health insurance. Most of my medical school education came from American textbooks, after all, so I thought it would be fabulous to be able to practice medicine the way it should be practiced because insurance will pay for it. (I know I sound like your elderly aunt that likes to repeat herself, but if you have not read any of my columns before, I come from the Philippines where health care is mostly paid for out of pocket, so how we treated patients was severely limited by how much the patient could afford.) I was wrong. I had no idea that part of my job description would include having to ask a corporate entity’s permission to administer treatments.

My boss replied to the letter. He said: “Patient is on dialysis and cannot be on methotrexate. He was prescribed a biologic, but your insurance does not cover its cost sufficiently to make it affordable. We had obtained the biologic through foundation support, but they ran out of money. So when you send out a letter like this blaming either the patient or MD for a compliance issue, I urge you to do some soul-searching.”

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

Some insurance companies recently started sending notifications about patient care. For example, one recently sent my boss a letter about one of his patients with rheumatoid arthritis, asking why the patient is not on a disease modifier. There is an invitation to explain why by ticking any one of several boxes. Is the patient perhaps not compliant? Did the patient discontinue the medication against the doctor’s advice? Has the patient passed away? Does the patient not have rheumatoid arthritis?

Oh, to be a fly on the wall when the insurance company decided that they would start doing this! This must impose a financial burden on the insurer, one that I cannot imagine they take on out of sheer altruism. What is the end game? What do they do with this information? Will they hold this information against the patient somehow, raise their premium in the next enrollment period? Or hold it against the physician, perhaps ding their reimbursement or use the information to include or exclude physicians from their panels?

When I decided to come to the United States, one of the biggest draws was the availability of health insurance. Most of my medical school education came from American textbooks, after all, so I thought it would be fabulous to be able to practice medicine the way it should be practiced because insurance will pay for it. (I know I sound like your elderly aunt that likes to repeat herself, but if you have not read any of my columns before, I come from the Philippines where health care is mostly paid for out of pocket, so how we treated patients was severely limited by how much the patient could afford.) I was wrong. I had no idea that part of my job description would include having to ask a corporate entity’s permission to administer treatments.

My boss replied to the letter. He said: “Patient is on dialysis and cannot be on methotrexate. He was prescribed a biologic, but your insurance does not cover its cost sufficiently to make it affordable. We had obtained the biologic through foundation support, but they ran out of money. So when you send out a letter like this blaming either the patient or MD for a compliance issue, I urge you to do some soul-searching.”

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

Some insurance companies recently started sending notifications about patient care. For example, one recently sent my boss a letter about one of his patients with rheumatoid arthritis, asking why the patient is not on a disease modifier. There is an invitation to explain why by ticking any one of several boxes. Is the patient perhaps not compliant? Did the patient discontinue the medication against the doctor’s advice? Has the patient passed away? Does the patient not have rheumatoid arthritis?

Oh, to be a fly on the wall when the insurance company decided that they would start doing this! This must impose a financial burden on the insurer, one that I cannot imagine they take on out of sheer altruism. What is the end game? What do they do with this information? Will they hold this information against the patient somehow, raise their premium in the next enrollment period? Or hold it against the physician, perhaps ding their reimbursement or use the information to include or exclude physicians from their panels?

When I decided to come to the United States, one of the biggest draws was the availability of health insurance. Most of my medical school education came from American textbooks, after all, so I thought it would be fabulous to be able to practice medicine the way it should be practiced because insurance will pay for it. (I know I sound like your elderly aunt that likes to repeat herself, but if you have not read any of my columns before, I come from the Philippines where health care is mostly paid for out of pocket, so how we treated patients was severely limited by how much the patient could afford.) I was wrong. I had no idea that part of my job description would include having to ask a corporate entity’s permission to administer treatments.

My boss replied to the letter. He said: “Patient is on dialysis and cannot be on methotrexate. He was prescribed a biologic, but your insurance does not cover its cost sufficiently to make it affordable. We had obtained the biologic through foundation support, but they ran out of money. So when you send out a letter like this blaming either the patient or MD for a compliance issue, I urge you to do some soul-searching.”

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

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

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

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

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

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

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

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

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

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

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

A month ago the American Board of Internal Medicine sent a letter to diplomates saying they “got it wrong,” referring to the process of maintenance of certification or MOC, that the board required. They acknowledged that “parts of the new program are not meeting the needs of physicians like yourself.” Some of the things they proposed include changing the content of the Internal Medicine recertification exam to be “more reflective of what physicians in practice are doing,” with a promise that subspecialty recertification exams will follow suit. They also talk about “new and more flexible ways ... to demonstrate ... medical knowledge,” likely making room for the continuing medical education or CME credits that state licensures require.

While the letter was evidence that physician grievances were being heard, it was widely criticized for not having gone far enough. Questions remained about the financial and time cost of certification, the relevance of the exam, and the motivation of the board.

Well, the ABIM has written us again. Except it’s still not saying much. They simply say that they have been listening to feedback, and they list some points about what they’ve been hearing and are presumably going to take into consideration. In summary, they are recognizing that the while we all agree that we need a way for physicians to keep up on their medical knowledge, there is “a shared sense that defining ‘keeping up’ is the work of the whole community, including physicians, specialty societies, patient groups, and health care institutions.”

They proceed to outline what they’ve heard and will presumably consider, including the suggestion that the recertification exam be eliminated completely, and that CME units count toward recertification. Like I said, they didn’t say much. But this is promising. Particularly telling is the part where they acknowledge that the job of defining ‘keeping up’ does not fall solely on, as a friend put it, people that sit in their ivory towers and are removed from the daily grind of patient care.

Apropos of all this, I recently got my first 10 points toward MOC by taking a 30-question exam posted by the American College of Rheumatology. Each question comes with a list of references that you can review should you need or want to. To my great surprise, one of the references was in German. So what does that tell you about the people writing the questions and the process they use? What does that tell you about the validity of the questions as a measure of my competence and ability to treat people?

Exams like the boards are a measure of test-taking skills and retention, neither one of which is a true measure of what a capable, competent physician should be. The ABIM is imposing on us an onerous and ill-conceived tool, one that most physicians agree is irrelevant. I am glad this conversation is happening, because frankly the process was enough to make me want to quit being a doctor.

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

Perhaps one of the biggest ways in which I’ve evolved as a doctor over the 4.5 years I’ve been in private practice is that I am not so shy about ordering tests anymore.

My point is illustrated by the case of a lovely lady I met when I was starting out in practice who complained of being in pain all the time. She was referred to me for a very low titer antinuclear antibody and a barely positive rheumatoid factor. She’d had a very long history of severe depression and anxiety. She clearly connected her symptoms to having stopped her antidepressants. She attributed her dry mouth to her benzodiazepine. I told her that I thought she had fibromyalgia and that, as she herself pointed out, it was probably related to her emotional health. We talked about the lack of any real pharmacologic treatment for the illness. We addressed self-care: that she needed to sleep better, exercise more, and treat her depression.

Three years later she came back to me with hand swelling, hypergammaglobulinemia, renal tubular acidosis, this time with significantly higher ANA and RF titers, and hypocomplementemia. You guessed it; she has Sjögren’s syndrome.

Seeing patients 40 hours a week has been incredibly challenging but also incredibly rewarding. While the large number of cases that I’ve seen has sharpened my clinical eye, it has also broadened my differential diagnoses and improved my knowledge of when it will be helpful to order more tests.

It used to be that I was extremely conservative about ordering tests. This comes from having gone to med school in the Philippines, where each test was paid for by the patient out of pocket and GDP per capita is $2,765 (compared with $53,041 for the United States) and minimum wage is less than 2 dollars a day. Every CBC has to count. If a professor asked you why you were ordering a test, “to establish a baseline” was an unacceptable reason. When I started residency here, I was incredulous that the admitted patients got a CBC and chem-7 daily. This seemed like a huge and unjustifiable waste to me.

Today, I am not so uptight. Of course, I am still extremely thoughtful about ordering tests. I do not order tests without knowing what I am looking for, or how the result will affect management. But I also recognize that there is a non-zero probability that what I suspect is fibromyalgia is something else, something with a different prognosis, better or worse, something that needs to be managed and monitored differently.

After all, “clinical judgment” does not mean relying on the history and physical exam alone. Good clinical judgment requires medical knowledge, informed by experience, supplemented by test results, and complemented by an open, inquisitive mind.

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

Perhaps one of the biggest ways in which I’ve evolved as a doctor over the 4.5 years I’ve been in private practice is that I am not so shy about ordering tests anymore.

My point is illustrated by the case of a lovely lady I met when I was starting out in practice who complained of being in pain all the time. She was referred to me for a very low titer antinuclear antibody and a barely positive rheumatoid factor. She’d had a very long history of severe depression and anxiety. She clearly connected her symptoms to having stopped her antidepressants. She attributed her dry mouth to her benzodiazepine. I told her that I thought she had fibromyalgia and that, as she herself pointed out, it was probably related to her emotional health. We talked about the lack of any real pharmacologic treatment for the illness. We addressed self-care: that she needed to sleep better, exercise more, and treat her depression.

Three years later she came back to me with hand swelling, hypergammaglobulinemia, renal tubular acidosis, this time with significantly higher ANA and RF titers, and hypocomplementemia. You guessed it; she has Sjögren’s syndrome.

Seeing patients 40 hours a week has been incredibly challenging but also incredibly rewarding. While the large number of cases that I’ve seen has sharpened my clinical eye, it has also broadened my differential diagnoses and improved my knowledge of when it will be helpful to order more tests.

It used to be that I was extremely conservative about ordering tests. This comes from having gone to med school in the Philippines, where each test was paid for by the patient out of pocket and GDP per capita is $2,765 (compared with $53,041 for the United States) and minimum wage is less than 2 dollars a day. Every CBC has to count. If a professor asked you why you were ordering a test, “to establish a baseline” was an unacceptable reason. When I started residency here, I was incredulous that the admitted patients got a CBC and chem-7 daily. This seemed like a huge and unjustifiable waste to me.

Today, I am not so uptight. Of course, I am still extremely thoughtful about ordering tests. I do not order tests without knowing what I am looking for, or how the result will affect management. But I also recognize that there is a non-zero probability that what I suspect is fibromyalgia is something else, something with a different prognosis, better or worse, something that needs to be managed and monitored differently.

After all, “clinical judgment” does not mean relying on the history and physical exam alone. Good clinical judgment requires medical knowledge, informed by experience, supplemented by test results, and complemented by an open, inquisitive mind.

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

Perhaps one of the biggest ways in which I’ve evolved as a doctor over the 4.5 years I’ve been in private practice is that I am not so shy about ordering tests anymore.

My point is illustrated by the case of a lovely lady I met when I was starting out in practice who complained of being in pain all the time. She was referred to me for a very low titer antinuclear antibody and a barely positive rheumatoid factor. She’d had a very long history of severe depression and anxiety. She clearly connected her symptoms to having stopped her antidepressants. She attributed her dry mouth to her benzodiazepine. I told her that I thought she had fibromyalgia and that, as she herself pointed out, it was probably related to her emotional health. We talked about the lack of any real pharmacologic treatment for the illness. We addressed self-care: that she needed to sleep better, exercise more, and treat her depression.

Three years later she came back to me with hand swelling, hypergammaglobulinemia, renal tubular acidosis, this time with significantly higher ANA and RF titers, and hypocomplementemia. You guessed it; she has Sjögren’s syndrome.

Seeing patients 40 hours a week has been incredibly challenging but also incredibly rewarding. While the large number of cases that I’ve seen has sharpened my clinical eye, it has also broadened my differential diagnoses and improved my knowledge of when it will be helpful to order more tests.

It used to be that I was extremely conservative about ordering tests. This comes from having gone to med school in the Philippines, where each test was paid for by the patient out of pocket and GDP per capita is $2,765 (compared with $53,041 for the United States) and minimum wage is less than 2 dollars a day. Every CBC has to count. If a professor asked you why you were ordering a test, “to establish a baseline” was an unacceptable reason. When I started residency here, I was incredulous that the admitted patients got a CBC and chem-7 daily. This seemed like a huge and unjustifiable waste to me.

Today, I am not so uptight. Of course, I am still extremely thoughtful about ordering tests. I do not order tests without knowing what I am looking for, or how the result will affect management. But I also recognize that there is a non-zero probability that what I suspect is fibromyalgia is something else, something with a different prognosis, better or worse, something that needs to be managed and monitored differently.

After all, “clinical judgment” does not mean relying on the history and physical exam alone. Good clinical judgment requires medical knowledge, informed by experience, supplemented by test results, and complemented by an open, inquisitive mind.

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

Some things make my job much harder than it should be. One of them is prior authorizations.

At the start of every year, insurers release a new formulary, so prior authorizations are often required, even drugs that patients have been on for a long time. Everyday I spend anywhere from 10 to 30 minutes filling out prior authorization paperwork.

Sometimes, it’s not too difficult. If someone is getting a biologic for the first time, it usually means they’ve had an inadequate response to methotrexate. The form makes sure we’ve checked the patient’s TB status. Sometimes, it asks about a history of heart failure. These are reasonable questions designed to protect the patient.

Frequently, though, the questionnaires are more onerous, and for less altruistic motives. A prior authorization for celecoxib (Celebrex) requires that I list at least two other prescription NSAIDs that the patient has been on. I can guarantee that I do not know that information off the top of my head, so this requires some digging into the chart. If it’s a patient whose care I’ve assumed from someone else, or whose chart is several volumes thick, I won’t even know where to begin. Even worse is the pregabalin (Lyrica) prior authorization that asks about previous use of tricyclic antidepressants, cyclobenzaprine, SSRIs, gabapentin. When were they on these agents and for how long? What was the outcome of each failed medication?

These two examples do not ensure patient safety. They simply go directly to what the insurer’s bottom line is. They benefit no one but the insurer, and create lots of problems for everyone who has to abide by the insurer’s rules.

The worst of it, this year, has to be prior authorization for injectable methotrexate. I have recently run into a lot of problems with this one. For one patient who had been on weekly adalimumab (Humira) and subcutaneous methotrexate, I was asked to justify the combination with a journal article or two, because mechanistically the insurers reject methotrexate as having any role in therapy for patients already on weekly adalimumab, antidrug antibodies notwithstanding. I had inherited this patient from another rheumatologist, and she’d been on this regimen for over a decade; it was infuriating and frustrating to be asked to justify a regimen that the patient had not had problems with for the previous 10 years and that was working fine for her.

For another patient, I was asked to fax a letter to the pharmacy stating why the drug was necessary. Then I was asked to fax another letter to the insurer’s benefits manager. A day later, I was informed that there was no process of appeal for medications that were not on formulary. None whatsoever. The letters that they had asked me to write had no bearing and meant nothing to them. This was the very definition of a complete waste of time.

If I wanted the patient to be on subcutaneous methotrexate, the patient would have to pay out of pocket for the drug. I got on the phone with someone whose job was to repeatedly tell me that I had no options. She couldn’t direct me to anyone higher up than her. I understand that this automaton would have no intelligent answers for me, but I asked rhetorically if etanercept would be covered. She said yes. I then asked rhetorically if she knew how much more the biologic agent would cost the insurance company. I cut her off as she was about to look up the price of the drug.

I can think of hundreds of ways in which I could make better use of my time instead of playing a game I am forced to play against my will, a game that is shrouded in layers of bureaucracy over which I have very little control and has no benefit to my patients. There are days when the game is enough to make me want to throw in the towel.

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

Some things make my job much harder than it should be. One of them is prior authorizations.

At the start of every year, insurers release a new formulary, so prior authorizations are often required, even drugs that patients have been on for a long time. Everyday I spend anywhere from 10 to 30 minutes filling out prior authorization paperwork.

Sometimes, it’s not too difficult. If someone is getting a biologic for the first time, it usually means they’ve had an inadequate response to methotrexate. The form makes sure we’ve checked the patient’s TB status. Sometimes, it asks about a history of heart failure. These are reasonable questions designed to protect the patient.

Frequently, though, the questionnaires are more onerous, and for less altruistic motives. A prior authorization for celecoxib (Celebrex) requires that I list at least two other prescription NSAIDs that the patient has been on. I can guarantee that I do not know that information off the top of my head, so this requires some digging into the chart. If it’s a patient whose care I’ve assumed from someone else, or whose chart is several volumes thick, I won’t even know where to begin. Even worse is the pregabalin (Lyrica) prior authorization that asks about previous use of tricyclic antidepressants, cyclobenzaprine, SSRIs, gabapentin. When were they on these agents and for how long? What was the outcome of each failed medication?

These two examples do not ensure patient safety. They simply go directly to what the insurer’s bottom line is. They benefit no one but the insurer, and create lots of problems for everyone who has to abide by the insurer’s rules.

The worst of it, this year, has to be prior authorization for injectable methotrexate. I have recently run into a lot of problems with this one. For one patient who had been on weekly adalimumab (Humira) and subcutaneous methotrexate, I was asked to justify the combination with a journal article or two, because mechanistically the insurers reject methotrexate as having any role in therapy for patients already on weekly adalimumab, antidrug antibodies notwithstanding. I had inherited this patient from another rheumatologist, and she’d been on this regimen for over a decade; it was infuriating and frustrating to be asked to justify a regimen that the patient had not had problems with for the previous 10 years and that was working fine for her.

For another patient, I was asked to fax a letter to the pharmacy stating why the drug was necessary. Then I was asked to fax another letter to the insurer’s benefits manager. A day later, I was informed that there was no process of appeal for medications that were not on formulary. None whatsoever. The letters that they had asked me to write had no bearing and meant nothing to them. This was the very definition of a complete waste of time.

If I wanted the patient to be on subcutaneous methotrexate, the patient would have to pay out of pocket for the drug. I got on the phone with someone whose job was to repeatedly tell me that I had no options. She couldn’t direct me to anyone higher up than her. I understand that this automaton would have no intelligent answers for me, but I asked rhetorically if etanercept would be covered. She said yes. I then asked rhetorically if she knew how much more the biologic agent would cost the insurance company. I cut her off as she was about to look up the price of the drug.

I can think of hundreds of ways in which I could make better use of my time instead of playing a game I am forced to play against my will, a game that is shrouded in layers of bureaucracy over which I have very little control and has no benefit to my patients. There are days when the game is enough to make me want to throw in the towel.

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

Some things make my job much harder than it should be. One of them is prior authorizations.

At the start of every year, insurers release a new formulary, so prior authorizations are often required, even drugs that patients have been on for a long time. Everyday I spend anywhere from 10 to 30 minutes filling out prior authorization paperwork.

Sometimes, it’s not too difficult. If someone is getting a biologic for the first time, it usually means they’ve had an inadequate response to methotrexate. The form makes sure we’ve checked the patient’s TB status. Sometimes, it asks about a history of heart failure. These are reasonable questions designed to protect the patient.

Frequently, though, the questionnaires are more onerous, and for less altruistic motives. A prior authorization for celecoxib (Celebrex) requires that I list at least two other prescription NSAIDs that the patient has been on. I can guarantee that I do not know that information off the top of my head, so this requires some digging into the chart. If it’s a patient whose care I’ve assumed from someone else, or whose chart is several volumes thick, I won’t even know where to begin. Even worse is the pregabalin (Lyrica) prior authorization that asks about previous use of tricyclic antidepressants, cyclobenzaprine, SSRIs, gabapentin. When were they on these agents and for how long? What was the outcome of each failed medication?

These two examples do not ensure patient safety. They simply go directly to what the insurer’s bottom line is. They benefit no one but the insurer, and create lots of problems for everyone who has to abide by the insurer’s rules.

The worst of it, this year, has to be prior authorization for injectable methotrexate. I have recently run into a lot of problems with this one. For one patient who had been on weekly adalimumab (Humira) and subcutaneous methotrexate, I was asked to justify the combination with a journal article or two, because mechanistically the insurers reject methotrexate as having any role in therapy for patients already on weekly adalimumab, antidrug antibodies notwithstanding. I had inherited this patient from another rheumatologist, and she’d been on this regimen for over a decade; it was infuriating and frustrating to be asked to justify a regimen that the patient had not had problems with for the previous 10 years and that was working fine for her.

For another patient, I was asked to fax a letter to the pharmacy stating why the drug was necessary. Then I was asked to fax another letter to the insurer’s benefits manager. A day later, I was informed that there was no process of appeal for medications that were not on formulary. None whatsoever. The letters that they had asked me to write had no bearing and meant nothing to them. This was the very definition of a complete waste of time.

If I wanted the patient to be on subcutaneous methotrexate, the patient would have to pay out of pocket for the drug. I got on the phone with someone whose job was to repeatedly tell me that I had no options. She couldn’t direct me to anyone higher up than her. I understand that this automaton would have no intelligent answers for me, but I asked rhetorically if etanercept would be covered. She said yes. I then asked rhetorically if she knew how much more the biologic agent would cost the insurance company. I cut her off as she was about to look up the price of the drug.

I can think of hundreds of ways in which I could make better use of my time instead of playing a game I am forced to play against my will, a game that is shrouded in layers of bureaucracy over which I have very little control and has no benefit to my patients. There are days when the game is enough to make me want to throw in the towel.

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

One of my pet peeves is when a patient or colleague speaks ill of another health care provider. I find it unbecoming behavior that often (though not always) speaks more to the character of the speaker than that of the object of anger/derision/dissatisfaction. I recently had the misfortune of interacting with a nurse practitioner who behaved in this manner. (The evidence of my hypocrisy does not escape me.)

A patient had been having some vague complaints for about 5 years, including myalgias, headaches, and fatigue. She remembers a tick bite that preceded the onset of symptoms. She tested negative for Lyme disease and other tick-borne illnesses multiple times, but after seeing many different doctors she finally saw an infectious disease doctor who often treats patients for what he diagnoses as a chronic Lyme infection. The patient was on antibiotics for about 5 years. But because she didn’t really feel any better, she started questioning the diagnosis.

I explained to the patient why I thought that fibromyalgia might explain her symptoms. She looked this up on the Internet and found that the disease described her symptoms completely. She was happy to stop antibiotic treatment. However, in the interest of leaving no stone unturned, I referred her to a neurologist for her headaches.

The nurse practitioner who evaluated her sent her for a brain single-photon emission computed tomography scan that showed “multifocal regions of decreased uptake, distribution suggestive of vasculitis or multi-infarct dementia.” The NP then informed the patient of this result, said it was consistent with CNS Lyme, and asked her to return to the infectious disease doctor who then put her back on oral antibiotics.

The patient brought this all to my attention, asking for an opinion. I thought she probably had small vessel changes because she had hyperlipidemia and was a heavy smoker. But I was curious about the decision to label this as CNS Lyme, so I thought I would touch base with the NP. What ensued was possibly one of the most disturbing conversations I’ve had with another health care provider since I started practice.

She didn’t think she needed a lumbar puncture to confirm her diagnosis. She hadn’t bothered to order Lyme serologies or to look for previous results. “We take the patient’s word for it,” she smugly told me. She had full confidence that her diagnosis was correct, because “we see this all the time.” When I said I thought, common things being common, that the cigarette smoking was the most likely culprit for the changes, her response was: “Common things being common, Lyme disease is pretty common around here.” On the question of why the patient was getting oral antibiotics rather than IV antibiotics per Infectious Diseases Society of America guidelines for CNS Lyme, the response I got was again, that she sees this “all the time, and they do respond to oral antibiotics.”

I think the worst part was that when I pointed out that the preponderance of other doctors (two primary care physicians, two infectious disease doctors, another neurologist, another rheumatologist, and myself) did not agree with the diagnosis, her reply was to say that “the ID docs around here are way too conservative when it comes to treating chronic Lyme.”

Of course, she could very well be correct in her diagnosis. However, the conceit with which she so readily accused the ID specialists of being “too conservative” when she clearly did not do the necessary work herself (LP, serologies, etc.) just rubs me the wrong way. Lazy and arrogant make a horrible combination.

I politely disagreed and ended the conversation, but I was so worked up about the situation that I decided to write about it, thereby demonstrating the same bad behavior I claim to dislike. I am afraid at this stage in my professional development magnanimity is not a quality that I yet possess. Hopefully, I will not have many opportunities to demonstrate my lack of it.

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

One of my pet peeves is when a patient or colleague speaks ill of another health care provider. I find it unbecoming behavior that often (though not always) speaks more to the character of the speaker than that of the object of anger/derision/dissatisfaction. I recently had the misfortune of interacting with a nurse practitioner who behaved in this manner. (The evidence of my hypocrisy does not escape me.)

A patient had been having some vague complaints for about 5 years, including myalgias, headaches, and fatigue. She remembers a tick bite that preceded the onset of symptoms. She tested negative for Lyme disease and other tick-borne illnesses multiple times, but after seeing many different doctors she finally saw an infectious disease doctor who often treats patients for what he diagnoses as a chronic Lyme infection. The patient was on antibiotics for about 5 years. But because she didn’t really feel any better, she started questioning the diagnosis.

I explained to the patient why I thought that fibromyalgia might explain her symptoms. She looked this up on the Internet and found that the disease described her symptoms completely. She was happy to stop antibiotic treatment. However, in the interest of leaving no stone unturned, I referred her to a neurologist for her headaches.

The nurse practitioner who evaluated her sent her for a brain single-photon emission computed tomography scan that showed “multifocal regions of decreased uptake, distribution suggestive of vasculitis or multi-infarct dementia.” The NP then informed the patient of this result, said it was consistent with CNS Lyme, and asked her to return to the infectious disease doctor who then put her back on oral antibiotics.

The patient brought this all to my attention, asking for an opinion. I thought she probably had small vessel changes because she had hyperlipidemia and was a heavy smoker. But I was curious about the decision to label this as CNS Lyme, so I thought I would touch base with the NP. What ensued was possibly one of the most disturbing conversations I’ve had with another health care provider since I started practice.

She didn’t think she needed a lumbar puncture to confirm her diagnosis. She hadn’t bothered to order Lyme serologies or to look for previous results. “We take the patient’s word for it,” she smugly told me. She had full confidence that her diagnosis was correct, because “we see this all the time.” When I said I thought, common things being common, that the cigarette smoking was the most likely culprit for the changes, her response was: “Common things being common, Lyme disease is pretty common around here.” On the question of why the patient was getting oral antibiotics rather than IV antibiotics per Infectious Diseases Society of America guidelines for CNS Lyme, the response I got was again, that she sees this “all the time, and they do respond to oral antibiotics.”

I think the worst part was that when I pointed out that the preponderance of other doctors (two primary care physicians, two infectious disease doctors, another neurologist, another rheumatologist, and myself) did not agree with the diagnosis, her reply was to say that “the ID docs around here are way too conservative when it comes to treating chronic Lyme.”

Of course, she could very well be correct in her diagnosis. However, the conceit with which she so readily accused the ID specialists of being “too conservative” when she clearly did not do the necessary work herself (LP, serologies, etc.) just rubs me the wrong way. Lazy and arrogant make a horrible combination.

I politely disagreed and ended the conversation, but I was so worked up about the situation that I decided to write about it, thereby demonstrating the same bad behavior I claim to dislike. I am afraid at this stage in my professional development magnanimity is not a quality that I yet possess. Hopefully, I will not have many opportunities to demonstrate my lack of it.

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

One of my pet peeves is when a patient or colleague speaks ill of another health care provider. I find it unbecoming behavior that often (though not always) speaks more to the character of the speaker than that of the object of anger/derision/dissatisfaction. I recently had the misfortune of interacting with a nurse practitioner who behaved in this manner. (The evidence of my hypocrisy does not escape me.)

A patient had been having some vague complaints for about 5 years, including myalgias, headaches, and fatigue. She remembers a tick bite that preceded the onset of symptoms. She tested negative for Lyme disease and other tick-borne illnesses multiple times, but after seeing many different doctors she finally saw an infectious disease doctor who often treats patients for what he diagnoses as a chronic Lyme infection. The patient was on antibiotics for about 5 years. But because she didn’t really feel any better, she started questioning the diagnosis.

I explained to the patient why I thought that fibromyalgia might explain her symptoms. She looked this up on the Internet and found that the disease described her symptoms completely. She was happy to stop antibiotic treatment. However, in the interest of leaving no stone unturned, I referred her to a neurologist for her headaches.

The nurse practitioner who evaluated her sent her for a brain single-photon emission computed tomography scan that showed “multifocal regions of decreased uptake, distribution suggestive of vasculitis or multi-infarct dementia.” The NP then informed the patient of this result, said it was consistent with CNS Lyme, and asked her to return to the infectious disease doctor who then put her back on oral antibiotics.

The patient brought this all to my attention, asking for an opinion. I thought she probably had small vessel changes because she had hyperlipidemia and was a heavy smoker. But I was curious about the decision to label this as CNS Lyme, so I thought I would touch base with the NP. What ensued was possibly one of the most disturbing conversations I’ve had with another health care provider since I started practice.

She didn’t think she needed a lumbar puncture to confirm her diagnosis. She hadn’t bothered to order Lyme serologies or to look for previous results. “We take the patient’s word for it,” she smugly told me. She had full confidence that her diagnosis was correct, because “we see this all the time.” When I said I thought, common things being common, that the cigarette smoking was the most likely culprit for the changes, her response was: “Common things being common, Lyme disease is pretty common around here.” On the question of why the patient was getting oral antibiotics rather than IV antibiotics per Infectious Diseases Society of America guidelines for CNS Lyme, the response I got was again, that she sees this “all the time, and they do respond to oral antibiotics.”

I think the worst part was that when I pointed out that the preponderance of other doctors (two primary care physicians, two infectious disease doctors, another neurologist, another rheumatologist, and myself) did not agree with the diagnosis, her reply was to say that “the ID docs around here are way too conservative when it comes to treating chronic Lyme.”

Of course, she could very well be correct in her diagnosis. However, the conceit with which she so readily accused the ID specialists of being “too conservative” when she clearly did not do the necessary work herself (LP, serologies, etc.) just rubs me the wrong way. Lazy and arrogant make a horrible combination.

I politely disagreed and ended the conversation, but I was so worked up about the situation that I decided to write about it, thereby demonstrating the same bad behavior I claim to dislike. I am afraid at this stage in my professional development magnanimity is not a quality that I yet possess. Hopefully, I will not have many opportunities to demonstrate my lack of it.

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

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

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

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

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

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

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