Rheum in Bloom

A few months ago, a nephrologist called me about a young, previously healthy health care worker who presented with an altered mental status, rapidly progressive renal failure, and rhabdomyolysis. It was an unusual combination of symptoms, and he had already ruled out the first things that came to my mind: drug toxicity, illicit drug use, thrombotic thrombocytopenic purpura-hemolytic-uremic syndrome. He wanted to know if I’d ever seen myositis present in this manner. I had not and could not think of ever having come across this as a possibility.

After powwowing with my bosses and coming up empty handed, I did what I do in these circumstances: I went to PubMed. Apart from illicit drug use, it seemed this constellation of symptoms was quite unusual. But there was one case report in an obscure emergency medicine journal from the 1980s, or perhaps it was the 1970s, of a patient that presented in just this manner and turned out to have Legionnaires’ disease.

I called the nephrologist back and told him about the case report. Although the patient had not reported a cough, he ran the test, and it came back positive.

Randomized, controlled trials are the philosopher’s stone of the scientific method, turning individual anecdotes into generalizable information, useful for large numbers of patients. But when doctors see unusual cases, we are often left with nothing but our own store of medical knowledge, informed by experience, imagination, and inquisitiveness. Intelligent speculation, to be sure, but hardly comforting to patient and physician alike.

It can be reassuring to know that other people have come across such unusual cases, just as it can be gratifying to know that our peers are interested in hearing our stories as well.

Counterfactuals are hard to come by in medicine, and we will never know what would have happened to the patient had I not seen that case report on PubMed. But the bias against case reports is such that it is probable that many illnesses remain undiagnosed simply because similar cases were deemed unworthy of publication.

There ought to be a repository of well-curated case reports. We are, all of us, made up of stories after all. And the stories that we tell are the art that temper this science we call Medicine.

Dr. Chan is a rheumatologist in Pawtucket, R.I.

A few months ago, a nephrologist called me about a young, previously healthy health care worker who presented with an altered mental status, rapidly progressive renal failure, and rhabdomyolysis. It was an unusual combination of symptoms, and he had already ruled out the first things that came to my mind: drug toxicity, illicit drug use, thrombotic thrombocytopenic purpura-hemolytic-uremic syndrome. He wanted to know if I’d ever seen myositis present in this manner. I had not and could not think of ever having come across this as a possibility.

After powwowing with my bosses and coming up empty handed, I did what I do in these circumstances: I went to PubMed. Apart from illicit drug use, it seemed this constellation of symptoms was quite unusual. But there was one case report in an obscure emergency medicine journal from the 1980s, or perhaps it was the 1970s, of a patient that presented in just this manner and turned out to have Legionnaires’ disease.

I called the nephrologist back and told him about the case report. Although the patient had not reported a cough, he ran the test, and it came back positive.

Randomized, controlled trials are the philosopher’s stone of the scientific method, turning individual anecdotes into generalizable information, useful for large numbers of patients. But when doctors see unusual cases, we are often left with nothing but our own store of medical knowledge, informed by experience, imagination, and inquisitiveness. Intelligent speculation, to be sure, but hardly comforting to patient and physician alike.

It can be reassuring to know that other people have come across such unusual cases, just as it can be gratifying to know that our peers are interested in hearing our stories as well.

Counterfactuals are hard to come by in medicine, and we will never know what would have happened to the patient had I not seen that case report on PubMed. But the bias against case reports is such that it is probable that many illnesses remain undiagnosed simply because similar cases were deemed unworthy of publication.

There ought to be a repository of well-curated case reports. We are, all of us, made up of stories after all. And the stories that we tell are the art that temper this science we call Medicine.

Dr. Chan is a rheumatologist in Pawtucket, R.I.

A few months ago, a nephrologist called me about a young, previously healthy health care worker who presented with an altered mental status, rapidly progressive renal failure, and rhabdomyolysis. It was an unusual combination of symptoms, and he had already ruled out the first things that came to my mind: drug toxicity, illicit drug use, thrombotic thrombocytopenic purpura-hemolytic-uremic syndrome. He wanted to know if I’d ever seen myositis present in this manner. I had not and could not think of ever having come across this as a possibility.

After powwowing with my bosses and coming up empty handed, I did what I do in these circumstances: I went to PubMed. Apart from illicit drug use, it seemed this constellation of symptoms was quite unusual. But there was one case report in an obscure emergency medicine journal from the 1980s, or perhaps it was the 1970s, of a patient that presented in just this manner and turned out to have Legionnaires’ disease.

I called the nephrologist back and told him about the case report. Although the patient had not reported a cough, he ran the test, and it came back positive.

Randomized, controlled trials are the philosopher’s stone of the scientific method, turning individual anecdotes into generalizable information, useful for large numbers of patients. But when doctors see unusual cases, we are often left with nothing but our own store of medical knowledge, informed by experience, imagination, and inquisitiveness. Intelligent speculation, to be sure, but hardly comforting to patient and physician alike.

It can be reassuring to know that other people have come across such unusual cases, just as it can be gratifying to know that our peers are interested in hearing our stories as well.

Counterfactuals are hard to come by in medicine, and we will never know what would have happened to the patient had I not seen that case report on PubMed. But the bias against case reports is such that it is probable that many illnesses remain undiagnosed simply because similar cases were deemed unworthy of publication.

There ought to be a repository of well-curated case reports. We are, all of us, made up of stories after all. And the stories that we tell are the art that temper this science we call Medicine.

Dr. Chan is a rheumatologist in Pawtucket, R.I.

I had a young cousin with thalassemia major. She had the textbook chipmunk facies, but you otherwise would not have known she was ill. Despite requiring blood transfusions every 3 weeks, she led a fairly normal life, graduating from college and holding down a good job.

In 2012, we found out that she had hepatitis C. She received treatment, but it did not succeed. By this point, she’d already developed cardiomyopathy, and she would later develop atrial fibrillation and heart failure. Earlier this year, Gilead was kind enough to give her its new drug sofosbuvir for free, but given her comorbidities, she could not tolerate it.

Recently, she was discharged after a protracted admission for heart failure. At that point, her hematologist, cardiologist, and hepatologist held a family meeting with her parents and siblings and pointed out the futility of her situation. Her family brought her home. They did what Filipino families in desperation do. They prayed and reached out to a “faith healer” – someone who uses poultices made from taro leaves, mutters incantations, and provides homemade remedies for any ailment. From a patient’s perspective, they provide hope where no one else will; from an outsider’s perspective, they are simply preying on the vulnerable.

Despite her family’s efforts, my cousin died about a month after coming home. She was only 27 years old. She woke up one morning feeling short of breath, weighed down by anasarca. She was brought to the hospital. Surrounded by her family, she asked her brother why he was crying. She asked her family not to bother calling her boyfriend; she’d talk to him when he came around. Then she fell asleep for the last time.

She did not know that she was dying. Her family had chosen to keep this from her.

When I learned about the circumstances of her passing I was angry and indignant at first. Why wouldn’t they tell her? What about patient self-determination and letting her be the judge of whether she wanted to be taken back to the hospital? Why would they deprive her of the opportunity to say goodbye? How is it that this sort of paternalistic, “I know what’s best for you” attitude still exists?

But I tried to put myself in her shoes, and it didn’t take long for me to question my certitude.

We romanticize the last moments of our lives. We imagine it to be filled with equanimity, a dignified acceptance of the inevitable. But that cannot always be the case. I can just as easily imagine myself to be angry, bitter, and, worst of all, fearful. Overwhelmed with sadness that it makes my last moments joyless rather than joyful.

Dying is intensely personal. Billions of people have led lives and reached endings unique to them. We may make noise about patient self-determination, but really, what is that if not just another manifestation of our arrogance that we know best? Is not insisting on patient self-determination just the other side of the same protect-the-patient-by-withholding-information coin?

I was humbled by my own ambivalence toward how her family handled her death, and a bit ashamed that I would be so quick to judge them. They did what they thought was best; who am I to question that? I may understand the science of life and death, but I cannot claim to understand living and dying.

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

I had a young cousin with thalassemia major. She had the textbook chipmunk facies, but you otherwise would not have known she was ill. Despite requiring blood transfusions every 3 weeks, she led a fairly normal life, graduating from college and holding down a good job.

In 2012, we found out that she had hepatitis C. She received treatment, but it did not succeed. By this point, she’d already developed cardiomyopathy, and she would later develop atrial fibrillation and heart failure. Earlier this year, Gilead was kind enough to give her its new drug sofosbuvir for free, but given her comorbidities, she could not tolerate it.

Recently, she was discharged after a protracted admission for heart failure. At that point, her hematologist, cardiologist, and hepatologist held a family meeting with her parents and siblings and pointed out the futility of her situation. Her family brought her home. They did what Filipino families in desperation do. They prayed and reached out to a “faith healer” – someone who uses poultices made from taro leaves, mutters incantations, and provides homemade remedies for any ailment. From a patient’s perspective, they provide hope where no one else will; from an outsider’s perspective, they are simply preying on the vulnerable.

Despite her family’s efforts, my cousin died about a month after coming home. She was only 27 years old. She woke up one morning feeling short of breath, weighed down by anasarca. She was brought to the hospital. Surrounded by her family, she asked her brother why he was crying. She asked her family not to bother calling her boyfriend; she’d talk to him when he came around. Then she fell asleep for the last time.

She did not know that she was dying. Her family had chosen to keep this from her.

When I learned about the circumstances of her passing I was angry and indignant at first. Why wouldn’t they tell her? What about patient self-determination and letting her be the judge of whether she wanted to be taken back to the hospital? Why would they deprive her of the opportunity to say goodbye? How is it that this sort of paternalistic, “I know what’s best for you” attitude still exists?

But I tried to put myself in her shoes, and it didn’t take long for me to question my certitude.

We romanticize the last moments of our lives. We imagine it to be filled with equanimity, a dignified acceptance of the inevitable. But that cannot always be the case. I can just as easily imagine myself to be angry, bitter, and, worst of all, fearful. Overwhelmed with sadness that it makes my last moments joyless rather than joyful.

Dying is intensely personal. Billions of people have led lives and reached endings unique to them. We may make noise about patient self-determination, but really, what is that if not just another manifestation of our arrogance that we know best? Is not insisting on patient self-determination just the other side of the same protect-the-patient-by-withholding-information coin?

I was humbled by my own ambivalence toward how her family handled her death, and a bit ashamed that I would be so quick to judge them. They did what they thought was best; who am I to question that? I may understand the science of life and death, but I cannot claim to understand living and dying.

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

I had a young cousin with thalassemia major. She had the textbook chipmunk facies, but you otherwise would not have known she was ill. Despite requiring blood transfusions every 3 weeks, she led a fairly normal life, graduating from college and holding down a good job.

In 2012, we found out that she had hepatitis C. She received treatment, but it did not succeed. By this point, she’d already developed cardiomyopathy, and she would later develop atrial fibrillation and heart failure. Earlier this year, Gilead was kind enough to give her its new drug sofosbuvir for free, but given her comorbidities, she could not tolerate it.

Recently, she was discharged after a protracted admission for heart failure. At that point, her hematologist, cardiologist, and hepatologist held a family meeting with her parents and siblings and pointed out the futility of her situation. Her family brought her home. They did what Filipino families in desperation do. They prayed and reached out to a “faith healer” – someone who uses poultices made from taro leaves, mutters incantations, and provides homemade remedies for any ailment. From a patient’s perspective, they provide hope where no one else will; from an outsider’s perspective, they are simply preying on the vulnerable.

Despite her family’s efforts, my cousin died about a month after coming home. She was only 27 years old. She woke up one morning feeling short of breath, weighed down by anasarca. She was brought to the hospital. Surrounded by her family, she asked her brother why he was crying. She asked her family not to bother calling her boyfriend; she’d talk to him when he came around. Then she fell asleep for the last time.

She did not know that she was dying. Her family had chosen to keep this from her.

When I learned about the circumstances of her passing I was angry and indignant at first. Why wouldn’t they tell her? What about patient self-determination and letting her be the judge of whether she wanted to be taken back to the hospital? Why would they deprive her of the opportunity to say goodbye? How is it that this sort of paternalistic, “I know what’s best for you” attitude still exists?

But I tried to put myself in her shoes, and it didn’t take long for me to question my certitude.

We romanticize the last moments of our lives. We imagine it to be filled with equanimity, a dignified acceptance of the inevitable. But that cannot always be the case. I can just as easily imagine myself to be angry, bitter, and, worst of all, fearful. Overwhelmed with sadness that it makes my last moments joyless rather than joyful.

Dying is intensely personal. Billions of people have led lives and reached endings unique to them. We may make noise about patient self-determination, but really, what is that if not just another manifestation of our arrogance that we know best? Is not insisting on patient self-determination just the other side of the same protect-the-patient-by-withholding-information coin?

I was humbled by my own ambivalence toward how her family handled her death, and a bit ashamed that I would be so quick to judge them. They did what they thought was best; who am I to question that? I may understand the science of life and death, but I cannot claim to understand living and dying.

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

"It is clear that physicians take widely different attitudes towards investigations, some relying on them much more heavily than others."

– J.R. Hampton, et al., British Medical Journal, May 31, 1975

In 1975, a study was published in the British Medical Journal looking at new patients referred to a medical clinic. The study looked specifically at how a diagnosis was made for each new patient, and it concluded that in 66 out of 80 patients, a diagnosis was arrived at based on the history alone, that the physical exam was useful in an additional 7 patients, and that lab testing was useful in the last 7 patients (Br. Med. J. 1975;2:486-9). Since then, medical students have been taught that a good history will lead to the diagnosis about 80% of the time.

One of my professors in my internal medicine class taught me this aphorism. I thought he was brilliant. Surely, anyone who can come up with a diagnosis just by talking to a patient is a minor god? (He is a rheumatologist. He became my mentor, and is, in fact, one of the major influences in my choice of specialty.)

Medical school in the Philippines forces one to think that way anyhow. There is very little government-provided health care; everything else is paid for out of pocket. This means that every CBC I order, every electrolyte panel, every antinuclear antibody, every urinalysis, is charged to the patient. There are not enough hospital beds, ventilators, or MRI machines.

So patients waited a while before seeking medical attention, which means we took full advantage of a history that’s remarkably evolved, with classic, textbook physical exam findings. The general medicine wards were crammed with patients with jaundice, whether from hepatitis or from having the carcass of a dead ascaris worm lodged in their bile ducts. We saw fungating breast masses. Hyperthyroidism is not that hard to identify when the patient is in frank thyrotoxicosis. Patients with pulmonary tuberculosis had massive hemoptysis, buckets of blood, and acid-fast bacilli in the emergency department.

This is the environment in which I trained. Could I say then that I would be able to identify a problem just from taking a history alone? If you had months’, nay, years’ worth of history to work with, you’d be able to identify the problem, too. I’ll bet doctors who practiced in the 1960s and 1970s in the United States had similar experiences, having the benefit of witnessing full-blown cases of anything and everything.

Do I practice this way now? Not at all.

But that isn’t to say I don’t take a good enough history or physical exam, it’s just that patients seek medical attention earlier, and we have so many more resources at our disposal. We have the ability to detect illness before it wreaks havoc. (There are other, less charitable interpretations of this behavior, such as lack of time, patient expectations, etc. But that’s a topic for another time.)

I have a great deal of respect for my mentors who practice with very real limitations. I have no doubt they are better doctors than I am. And, of course, I feel nostalgic for the way we used to do things. It is easy to romanticize the sepia-toned snapshots of my third-world youth. But really, modernity is a blessing. We should celebrate our ability to find things early. Nostalgia is for meals and memories. Medicine is much more pedestrian than that.

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

"It is clear that physicians take widely different attitudes towards investigations, some relying on them much more heavily than others."

– J.R. Hampton, et al., British Medical Journal, May 31, 1975

In 1975, a study was published in the British Medical Journal looking at new patients referred to a medical clinic. The study looked specifically at how a diagnosis was made for each new patient, and it concluded that in 66 out of 80 patients, a diagnosis was arrived at based on the history alone, that the physical exam was useful in an additional 7 patients, and that lab testing was useful in the last 7 patients (Br. Med. J. 1975;2:486-9). Since then, medical students have been taught that a good history will lead to the diagnosis about 80% of the time.

One of my professors in my internal medicine class taught me this aphorism. I thought he was brilliant. Surely, anyone who can come up with a diagnosis just by talking to a patient is a minor god? (He is a rheumatologist. He became my mentor, and is, in fact, one of the major influences in my choice of specialty.)

Medical school in the Philippines forces one to think that way anyhow. There is very little government-provided health care; everything else is paid for out of pocket. This means that every CBC I order, every electrolyte panel, every antinuclear antibody, every urinalysis, is charged to the patient. There are not enough hospital beds, ventilators, or MRI machines.

So patients waited a while before seeking medical attention, which means we took full advantage of a history that’s remarkably evolved, with classic, textbook physical exam findings. The general medicine wards were crammed with patients with jaundice, whether from hepatitis or from having the carcass of a dead ascaris worm lodged in their bile ducts. We saw fungating breast masses. Hyperthyroidism is not that hard to identify when the patient is in frank thyrotoxicosis. Patients with pulmonary tuberculosis had massive hemoptysis, buckets of blood, and acid-fast bacilli in the emergency department.

This is the environment in which I trained. Could I say then that I would be able to identify a problem just from taking a history alone? If you had months’, nay, years’ worth of history to work with, you’d be able to identify the problem, too. I’ll bet doctors who practiced in the 1960s and 1970s in the United States had similar experiences, having the benefit of witnessing full-blown cases of anything and everything.

Do I practice this way now? Not at all.

But that isn’t to say I don’t take a good enough history or physical exam, it’s just that patients seek medical attention earlier, and we have so many more resources at our disposal. We have the ability to detect illness before it wreaks havoc. (There are other, less charitable interpretations of this behavior, such as lack of time, patient expectations, etc. But that’s a topic for another time.)

I have a great deal of respect for my mentors who practice with very real limitations. I have no doubt they are better doctors than I am. And, of course, I feel nostalgic for the way we used to do things. It is easy to romanticize the sepia-toned snapshots of my third-world youth. But really, modernity is a blessing. We should celebrate our ability to find things early. Nostalgia is for meals and memories. Medicine is much more pedestrian than that.

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

"It is clear that physicians take widely different attitudes towards investigations, some relying on them much more heavily than others."

– J.R. Hampton, et al., British Medical Journal, May 31, 1975

In 1975, a study was published in the British Medical Journal looking at new patients referred to a medical clinic. The study looked specifically at how a diagnosis was made for each new patient, and it concluded that in 66 out of 80 patients, a diagnosis was arrived at based on the history alone, that the physical exam was useful in an additional 7 patients, and that lab testing was useful in the last 7 patients (Br. Med. J. 1975;2:486-9). Since then, medical students have been taught that a good history will lead to the diagnosis about 80% of the time.

One of my professors in my internal medicine class taught me this aphorism. I thought he was brilliant. Surely, anyone who can come up with a diagnosis just by talking to a patient is a minor god? (He is a rheumatologist. He became my mentor, and is, in fact, one of the major influences in my choice of specialty.)

Medical school in the Philippines forces one to think that way anyhow. There is very little government-provided health care; everything else is paid for out of pocket. This means that every CBC I order, every electrolyte panel, every antinuclear antibody, every urinalysis, is charged to the patient. There are not enough hospital beds, ventilators, or MRI machines.

So patients waited a while before seeking medical attention, which means we took full advantage of a history that’s remarkably evolved, with classic, textbook physical exam findings. The general medicine wards were crammed with patients with jaundice, whether from hepatitis or from having the carcass of a dead ascaris worm lodged in their bile ducts. We saw fungating breast masses. Hyperthyroidism is not that hard to identify when the patient is in frank thyrotoxicosis. Patients with pulmonary tuberculosis had massive hemoptysis, buckets of blood, and acid-fast bacilli in the emergency department.

This is the environment in which I trained. Could I say then that I would be able to identify a problem just from taking a history alone? If you had months’, nay, years’ worth of history to work with, you’d be able to identify the problem, too. I’ll bet doctors who practiced in the 1960s and 1970s in the United States had similar experiences, having the benefit of witnessing full-blown cases of anything and everything.

Do I practice this way now? Not at all.

But that isn’t to say I don’t take a good enough history or physical exam, it’s just that patients seek medical attention earlier, and we have so many more resources at our disposal. We have the ability to detect illness before it wreaks havoc. (There are other, less charitable interpretations of this behavior, such as lack of time, patient expectations, etc. But that’s a topic for another time.)

I have a great deal of respect for my mentors who practice with very real limitations. I have no doubt they are better doctors than I am. And, of course, I feel nostalgic for the way we used to do things. It is easy to romanticize the sepia-toned snapshots of my third-world youth. But really, modernity is a blessing. We should celebrate our ability to find things early. Nostalgia is for meals and memories. Medicine is much more pedestrian than that.

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

"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."

–Monty Python, "The Meaning of Life"

1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.

2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.

3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.

4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.

5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.

6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.

7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)

8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.

9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.

10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.

11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.

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

"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."

–Monty Python, "The Meaning of Life"

1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.

2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.

3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.

4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.

5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.

6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.

7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)

8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.

9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.

10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.

11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.

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

"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."

–Monty Python, "The Meaning of Life"

1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.

2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.

3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.

4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.

5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.

6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.

7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)

8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.

9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.

10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.

11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.

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

In my first year of fellowship, I met a delightful old man who had temporal arteritis. We naturally treated him with steroids, but he consequently suffered a vertebral fracture. He passed away soon after that from pneumonia that was probably aggravated by his inability to breathe deeply and cough appropriately.

An elderly patient with rheumatoid arthritis was diagnosed with lymphoma. For want of something to blame, his children blamed it on the methotrexate.

A woman with lupus nephritis got pregnant while on mycophenolate despite being on contraception. Her baby was born with malformed ears and eyes, and by all accounts will probably be deaf and blind.

We have been gifted with this mind-blowing ability to make our patients’ lives much better. That sense of accomplishment can be intoxicating. After all, how many of your polymyalgia rheumatica patients worship you because you made the diagnosis and made them 100% better by putting them on prednisone? Yet we forget that although bad things rarely happen, that does not mean that they won’t happen.

In a beautiful book called "Where’d You Go, Bernadette?" the husband of the title character says that the brain is a discounting mechanism: "Let’s say you get a crack in your windshield and you’re really upset. Oh no, my windshield, it’s ruined, I can hardly see out of it, this is a tragedy! But you don’t have enough money to fix it, so you drive with it. In a month, someone asks you what happened to your windshield, and you say, What do you mean? Because your brain has discounted it. ... It’s for survival. You need to be prepared for novel experiences because often they signal danger."

The book is about an artist who we are led to believe has completed her downward spiral, going from genius to wacko. In the above passage, the artist’s husband is explaining to their daughter why they loved their family home so much, despite its state of extreme disrepair. They loved the house so much that they couldn’t see that it was a safety hazard.

As a fresh graduate I insisted on weaning everyone off prednisone, terrified of the potential side effects. Five years later and with the benefit of the collected wisdom of hundreds of rheumatologists before me, I have accepted that some people need a low dose of steroid to keep their disease quiet. I have used this and other, more toxic drugs to such great effects – taking for granted their ability to make people better – that I forget sometimes that they can cause serious problems.

Bad outcomes can and do happen in spite of our best intentions. In my case, my default is to blame myself. In my more melodramatic moments, I wonder if I deserve to be a doctor. But when I am done feeling angry or sad, or, frankly, feeling sorry for myself, then I need that discounting mechanism to kick in, to remind myself that this is one bad outcome out of many good outcomes. There are things beyond my control, and I cannot let a bad outcome keep me from doing the good work that I am still able to do.

There is a scene from the TV series "The West Wing" where the president asks one of his staffers if he thought the president was being kept from doing a great job because his demons were "shouting down the better angels" in his brain. Thankfully, my brain’s discounting mechanism helps keep the demons at bay.

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

In my first year of fellowship, I met a delightful old man who had temporal arteritis. We naturally treated him with steroids, but he consequently suffered a vertebral fracture. He passed away soon after that from pneumonia that was probably aggravated by his inability to breathe deeply and cough appropriately.

An elderly patient with rheumatoid arthritis was diagnosed with lymphoma. For want of something to blame, his children blamed it on the methotrexate.

A woman with lupus nephritis got pregnant while on mycophenolate despite being on contraception. Her baby was born with malformed ears and eyes, and by all accounts will probably be deaf and blind.

We have been gifted with this mind-blowing ability to make our patients’ lives much better. That sense of accomplishment can be intoxicating. After all, how many of your polymyalgia rheumatica patients worship you because you made the diagnosis and made them 100% better by putting them on prednisone? Yet we forget that although bad things rarely happen, that does not mean that they won’t happen.

In a beautiful book called "Where’d You Go, Bernadette?" the husband of the title character says that the brain is a discounting mechanism: "Let’s say you get a crack in your windshield and you’re really upset. Oh no, my windshield, it’s ruined, I can hardly see out of it, this is a tragedy! But you don’t have enough money to fix it, so you drive with it. In a month, someone asks you what happened to your windshield, and you say, What do you mean? Because your brain has discounted it. ... It’s for survival. You need to be prepared for novel experiences because often they signal danger."

The book is about an artist who we are led to believe has completed her downward spiral, going from genius to wacko. In the above passage, the artist’s husband is explaining to their daughter why they loved their family home so much, despite its state of extreme disrepair. They loved the house so much that they couldn’t see that it was a safety hazard.

As a fresh graduate I insisted on weaning everyone off prednisone, terrified of the potential side effects. Five years later and with the benefit of the collected wisdom of hundreds of rheumatologists before me, I have accepted that some people need a low dose of steroid to keep their disease quiet. I have used this and other, more toxic drugs to such great effects – taking for granted their ability to make people better – that I forget sometimes that they can cause serious problems.

Bad outcomes can and do happen in spite of our best intentions. In my case, my default is to blame myself. In my more melodramatic moments, I wonder if I deserve to be a doctor. But when I am done feeling angry or sad, or, frankly, feeling sorry for myself, then I need that discounting mechanism to kick in, to remind myself that this is one bad outcome out of many good outcomes. There are things beyond my control, and I cannot let a bad outcome keep me from doing the good work that I am still able to do.

There is a scene from the TV series "The West Wing" where the president asks one of his staffers if he thought the president was being kept from doing a great job because his demons were "shouting down the better angels" in his brain. Thankfully, my brain’s discounting mechanism helps keep the demons at bay.

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

In my first year of fellowship, I met a delightful old man who had temporal arteritis. We naturally treated him with steroids, but he consequently suffered a vertebral fracture. He passed away soon after that from pneumonia that was probably aggravated by his inability to breathe deeply and cough appropriately.

An elderly patient with rheumatoid arthritis was diagnosed with lymphoma. For want of something to blame, his children blamed it on the methotrexate.

A woman with lupus nephritis got pregnant while on mycophenolate despite being on contraception. Her baby was born with malformed ears and eyes, and by all accounts will probably be deaf and blind.

We have been gifted with this mind-blowing ability to make our patients’ lives much better. That sense of accomplishment can be intoxicating. After all, how many of your polymyalgia rheumatica patients worship you because you made the diagnosis and made them 100% better by putting them on prednisone? Yet we forget that although bad things rarely happen, that does not mean that they won’t happen.

In a beautiful book called "Where’d You Go, Bernadette?" the husband of the title character says that the brain is a discounting mechanism: "Let’s say you get a crack in your windshield and you’re really upset. Oh no, my windshield, it’s ruined, I can hardly see out of it, this is a tragedy! But you don’t have enough money to fix it, so you drive with it. In a month, someone asks you what happened to your windshield, and you say, What do you mean? Because your brain has discounted it. ... It’s for survival. You need to be prepared for novel experiences because often they signal danger."

The book is about an artist who we are led to believe has completed her downward spiral, going from genius to wacko. In the above passage, the artist’s husband is explaining to their daughter why they loved their family home so much, despite its state of extreme disrepair. They loved the house so much that they couldn’t see that it was a safety hazard.

As a fresh graduate I insisted on weaning everyone off prednisone, terrified of the potential side effects. Five years later and with the benefit of the collected wisdom of hundreds of rheumatologists before me, I have accepted that some people need a low dose of steroid to keep their disease quiet. I have used this and other, more toxic drugs to such great effects – taking for granted their ability to make people better – that I forget sometimes that they can cause serious problems.

Bad outcomes can and do happen in spite of our best intentions. In my case, my default is to blame myself. In my more melodramatic moments, I wonder if I deserve to be a doctor. But when I am done feeling angry or sad, or, frankly, feeling sorry for myself, then I need that discounting mechanism to kick in, to remind myself that this is one bad outcome out of many good outcomes. There are things beyond my control, and I cannot let a bad outcome keep me from doing the good work that I am still able to do.

There is a scene from the TV series "The West Wing" where the president asks one of his staffers if he thought the president was being kept from doing a great job because his demons were "shouting down the better angels" in his brain. Thankfully, my brain’s discounting mechanism helps keep the demons at bay.

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

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

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

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

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

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

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

7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.

8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.

8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.

9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.

12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.

12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)

1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)

3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.

3:20 p.m. Some ice cream regret going on here.

4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.

6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.

6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A_1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.

7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.

8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.

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

7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.

8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.

8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.

9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.

12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.

12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)

1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)

3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.

3:20 p.m. Some ice cream regret going on here.

4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.

6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.

6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A_1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.

7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.

8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.

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

7:00 a.m. When they called me for this consult on this young female with known lupus presenting with pleuritic chest pain, they didn’t tell me that (a) she has a history of pleural effusions, and (b) her creatinine is 4.9 mg/dL.

8:00 a.m. Waiting for my patient to be roomed. We’re implementing a new electronic health record, so I have to wait for the medical assistant (MA) to finish her tasks: input the patient’s medications, take his vital signs, and ask for his chief complaint.

8:20 a.m. Patient is still not ready for me. Who thought it would be a good idea for the MA to take the patient’s medications? It’d be so much more efficient if I did it myself.

9:00 a.m. Finally finished with the first patient. It was a follow-up visit that was scheduled as 15 minutes. I am now 45 minutes behind schedule. Thankfully, the MA managed to use the 45 minutes to room the 8:15 patient.

12:30 p.m. Whew, I just finished my morning. I start again in 30 minutes. I am never going to finish these 12 charts in 30 minutes. Also, I am hungry. If I don’t eat now, I am going to have my MA for lunch.

12:45 p.m. Speaking to Dr. Winchester from Blue Cross to get approval for a contrast MRI of the right foot. (This call may be recorded. What did your x-rays show? Have you failed conservative treatment? Will it change management? Here’s your approval number.)

1:00 p.m. The new patient is here. She is the proud owner of a very long med list. It’ll probably take the MA 30 minutes to get through all that. Let me call dermatology in the meantime; I need a full-thickness skin biopsy on Mrs. Rodrigues. (One week later, biopsy shows polyarteritis nodosa.)

3:15 p.m. I just finished a visit with Silvi. Her rheumatoid arthritis is quiescent, but she is in tears. Not only did her mother die unexpectedly from a ruptured aneurysm 2 months ago, she has just received a new diagnosis of breast cancer, and her husband lost his job. I can’t make this stuff up. That was an emotionally draining visit. I need a drink. Oh wait, there are no drinks to be had at a doctor’s office. Maybe the drug rep brought some ice cream.

3:20 p.m. Some ice cream regret going on here.

4:40 p.m. Just got done with a new-patient consultation for a "positive" antinuclear antibody test of 1:40 and a positive systems review. I’m exhausted.

6:15 p.m. Returning phone calls. Mrs. Greggerson is regaling me with details of her ablutions.

6:35 p.m. Filling out prior authorization forms for a biologic. Among the questions: A_1c, T score, growth velocity, Mini-Mental State Exam, free and total testosterone, hepatitis C viral load and genotype. I would like to officially nominate this form for Most Number of Irrelevant Questions Ever.

7:00 p.m. Finally, last prior-authorization form for the day. Wait ... it’s for methotrexate? Since when have I needed to get prior authorization for methotrexate? I didn’t think it was even possible for me to get any angrier after the Mini-Mental State question.

8:00 p.m. Finally home. I’m too beat to go to the gym. My good decision–making reserves are exhausted. I would rather have a glass of red. The resveratrol will do me more good than a workout.

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

Our bodies are amazing feats of nature

Pathways that we understand through science

Among the most complex though, I would wager

Immunity, autoimmunity, and balance.

First there is the issue of barriers,

Skin, and gut, and membranes

Primary defense against invaders

Seems ordinary, but really far from mundane.

What comes next is not pure serendipity

Not chance but an evolutionary gift

We kill germs with innate immunity

Imprecise but efficient and swift.

Phagocytes, a fitting name for greed

Neutrophils, macrophages, dendritic cells

Summoned to areas of injury, they proceed

To ingest and digest and clear dead cells.

Complement, a cascade of proteases

Opsonize invading pathogens

Activated by three different pathways

Membrane attack complex a terminal engine.

Simultaneously, adaptive immunity

In special regions, lymph nodes and Peyer’s patches

B cells develop some memory

Immunoglobulins churned out in batches.

Helper Ts aid antibody production

Cytotoxic Ts kill the bugs hiding within

Regulatory Ts promote self toleration

MHCs on cell surfaces weigh in.

Many elements require orchestration

Helped along by a bevy of proteins

Chemokines, interleukins, growth factors, interferons

Enzymatic cascades form routine.

This cellular/molecular adventure

Fantastically intricate choreography

Self or non-self, intruder, interloper

Defense against microbial tomfoolery.

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

Our bodies are amazing feats of nature

Pathways that we understand through science

Among the most complex though, I would wager

Immunity, autoimmunity, and balance.

First there is the issue of barriers,

Skin, and gut, and membranes

Primary defense against invaders

Seems ordinary, but really far from mundane.

What comes next is not pure serendipity

Not chance but an evolutionary gift

We kill germs with innate immunity

Imprecise but efficient and swift.

Phagocytes, a fitting name for greed

Neutrophils, macrophages, dendritic cells

Summoned to areas of injury, they proceed

To ingest and digest and clear dead cells.

Complement, a cascade of proteases

Opsonize invading pathogens

Activated by three different pathways

Membrane attack complex a terminal engine.

Simultaneously, adaptive immunity

In special regions, lymph nodes and Peyer’s patches

B cells develop some memory

Immunoglobulins churned out in batches.

Helper Ts aid antibody production

Cytotoxic Ts kill the bugs hiding within

Regulatory Ts promote self toleration

MHCs on cell surfaces weigh in.

Many elements require orchestration

Helped along by a bevy of proteins

Chemokines, interleukins, growth factors, interferons

Enzymatic cascades form routine.

This cellular/molecular adventure

Fantastically intricate choreography

Self or non-self, intruder, interloper

Defense against microbial tomfoolery.

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

Our bodies are amazing feats of nature

Pathways that we understand through science

Among the most complex though, I would wager

Immunity, autoimmunity, and balance.

First there is the issue of barriers,

Skin, and gut, and membranes

Primary defense against invaders

Seems ordinary, but really far from mundane.

What comes next is not pure serendipity

Not chance but an evolutionary gift

We kill germs with innate immunity

Imprecise but efficient and swift.

Phagocytes, a fitting name for greed

Neutrophils, macrophages, dendritic cells

Summoned to areas of injury, they proceed

To ingest and digest and clear dead cells.

Complement, a cascade of proteases

Opsonize invading pathogens

Activated by three different pathways

Membrane attack complex a terminal engine.

Simultaneously, adaptive immunity

In special regions, lymph nodes and Peyer’s patches

B cells develop some memory

Immunoglobulins churned out in batches.

Helper Ts aid antibody production

Cytotoxic Ts kill the bugs hiding within

Regulatory Ts promote self toleration

MHCs on cell surfaces weigh in.

Many elements require orchestration

Helped along by a bevy of proteins

Chemokines, interleukins, growth factors, interferons

Enzymatic cascades form routine.

This cellular/molecular adventure

Fantastically intricate choreography

Self or non-self, intruder, interloper

Defense against microbial tomfoolery.

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

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

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

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

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

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

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

I’ve just come across a really interesting project that I think we can all get behind: tuberculosis-sniffing rats.

It started with land mines. In many war-torn regions in Africa, people cannot access their land for agriculture because it is riddled with mines left over from previous conflicts. Bart Weetjens, a Belgian product development engineer with some experience of the difficulties of living in rural Africa, came across American experiments from the 1970s using gerbils to sniff out explosives. This inspired him to look into using rats to sniff out land mines. In 1997, he founded a nonprofit called Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling (APOPO) and received funding from the Belgian government to pursue his research.

Weetjens settled on using African giant pouch rats to sniff out land mines. The rats were inexpensive, intelligent, plentiful, sociable, trainable, and, most importantly, light enough to not set the land mines off. In 2003, they first tested the rats on real fields with real land mines in Mozambique. Now, they’ve received the backing of international peace agencies and have, to date, rendered safe 2.5 million square-meters of land area in Mozambique, effectively returning 100,000 people to their lands.

Given the success of this project, and the prevalence of pulmonary tuberculosis (TB) in the same communities affected by land mines, Weetjens thought of expanding the project into detection of tuberculosis from sputum samples. The premise is that Mycobacterium tuberculosis emits volatile organic compounds that the rats, with more genetic material dedicated to olfaction than any other mammal, might be able to detect.

It’s a fascinating demonstration of the intersection between science fiction and reality. You have to watch the videos to believe it, but the organization has trained several dozen rats in Tanzania and Mozambique to sniff out TB. It takes the rats 20 msec to sniff out and correctly identify a sample. The rats are able to process in 7 minutes the number of samples that a lab technician (or a lab "rat," if you will) would take a day to process using conventional light microscopy methods. In Dar es Salaam, using samples from more than 10,500 people from five hospitals, they increased the case detection rate by 44% over that of conventional microscopy. This method has a sensitivity of about 85% and a specificity of 90% – about the same rates as a 10-mm positive tuberculin test (Am. J. Trop. Med. Hyg. 2010;83:1308-10). It is even able to distinguish between M. tuberculosis and other mycobacterial species.

According to the World Health Organization, people with active tuberculosis can spread the disease to 10-15 close contacts in a year. WHO also says that TB is the second biggest infectious killer (behind HIV) worldwide, with over 1.3 million deaths in 2012. If these rats can really detect patients with TB at a much higher rate and with a greater sensitivity than standard microscopy, imagine the impact they would have on reducing the number of deaths worldwide from TB, especially in African nations where TB and HIV often co-occur, and access to health care is difficult.

APOPO’s project is a wonderful example of how simple innovations in science can have such a large footprint on global health. If you’re interested in learning more about APOPO, visit their website. You’ll find interesting videos and links to publications, plus ways to donate.

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

I’ve just come across a really interesting project that I think we can all get behind: tuberculosis-sniffing rats.

It started with land mines. In many war-torn regions in Africa, people cannot access their land for agriculture because it is riddled with mines left over from previous conflicts. Bart Weetjens, a Belgian product development engineer with some experience of the difficulties of living in rural Africa, came across American experiments from the 1970s using gerbils to sniff out explosives. This inspired him to look into using rats to sniff out land mines. In 1997, he founded a nonprofit called Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling (APOPO) and received funding from the Belgian government to pursue his research.

Weetjens settled on using African giant pouch rats to sniff out land mines. The rats were inexpensive, intelligent, plentiful, sociable, trainable, and, most importantly, light enough to not set the land mines off. In 2003, they first tested the rats on real fields with real land mines in Mozambique. Now, they’ve received the backing of international peace agencies and have, to date, rendered safe 2.5 million square-meters of land area in Mozambique, effectively returning 100,000 people to their lands.

Given the success of this project, and the prevalence of pulmonary tuberculosis (TB) in the same communities affected by land mines, Weetjens thought of expanding the project into detection of tuberculosis from sputum samples. The premise is that Mycobacterium tuberculosis emits volatile organic compounds that the rats, with more genetic material dedicated to olfaction than any other mammal, might be able to detect.

It’s a fascinating demonstration of the intersection between science fiction and reality. You have to watch the videos to believe it, but the organization has trained several dozen rats in Tanzania and Mozambique to sniff out TB. It takes the rats 20 msec to sniff out and correctly identify a sample. The rats are able to process in 7 minutes the number of samples that a lab technician (or a lab "rat," if you will) would take a day to process using conventional light microscopy methods. In Dar es Salaam, using samples from more than 10,500 people from five hospitals, they increased the case detection rate by 44% over that of conventional microscopy. This method has a sensitivity of about 85% and a specificity of 90% – about the same rates as a 10-mm positive tuberculin test (Am. J. Trop. Med. Hyg. 2010;83:1308-10). It is even able to distinguish between M. tuberculosis and other mycobacterial species.

According to the World Health Organization, people with active tuberculosis can spread the disease to 10-15 close contacts in a year. WHO also says that TB is the second biggest infectious killer (behind HIV) worldwide, with over 1.3 million deaths in 2012. If these rats can really detect patients with TB at a much higher rate and with a greater sensitivity than standard microscopy, imagine the impact they would have on reducing the number of deaths worldwide from TB, especially in African nations where TB and HIV often co-occur, and access to health care is difficult.

APOPO’s project is a wonderful example of how simple innovations in science can have such a large footprint on global health. If you’re interested in learning more about APOPO, visit their website. You’ll find interesting videos and links to publications, plus ways to donate.

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

I’ve just come across a really interesting project that I think we can all get behind: tuberculosis-sniffing rats.

It started with land mines. In many war-torn regions in Africa, people cannot access their land for agriculture because it is riddled with mines left over from previous conflicts. Bart Weetjens, a Belgian product development engineer with some experience of the difficulties of living in rural Africa, came across American experiments from the 1970s using gerbils to sniff out explosives. This inspired him to look into using rats to sniff out land mines. In 1997, he founded a nonprofit called Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling (APOPO) and received funding from the Belgian government to pursue his research.

Weetjens settled on using African giant pouch rats to sniff out land mines. The rats were inexpensive, intelligent, plentiful, sociable, trainable, and, most importantly, light enough to not set the land mines off. In 2003, they first tested the rats on real fields with real land mines in Mozambique. Now, they’ve received the backing of international peace agencies and have, to date, rendered safe 2.5 million square-meters of land area in Mozambique, effectively returning 100,000 people to their lands.

Given the success of this project, and the prevalence of pulmonary tuberculosis (TB) in the same communities affected by land mines, Weetjens thought of expanding the project into detection of tuberculosis from sputum samples. The premise is that Mycobacterium tuberculosis emits volatile organic compounds that the rats, with more genetic material dedicated to olfaction than any other mammal, might be able to detect.

It’s a fascinating demonstration of the intersection between science fiction and reality. You have to watch the videos to believe it, but the organization has trained several dozen rats in Tanzania and Mozambique to sniff out TB. It takes the rats 20 msec to sniff out and correctly identify a sample. The rats are able to process in 7 minutes the number of samples that a lab technician (or a lab "rat," if you will) would take a day to process using conventional light microscopy methods. In Dar es Salaam, using samples from more than 10,500 people from five hospitals, they increased the case detection rate by 44% over that of conventional microscopy. This method has a sensitivity of about 85% and a specificity of 90% – about the same rates as a 10-mm positive tuberculin test (Am. J. Trop. Med. Hyg. 2010;83:1308-10). It is even able to distinguish between M. tuberculosis and other mycobacterial species.

According to the World Health Organization, people with active tuberculosis can spread the disease to 10-15 close contacts in a year. WHO also says that TB is the second biggest infectious killer (behind HIV) worldwide, with over 1.3 million deaths in 2012. If these rats can really detect patients with TB at a much higher rate and with a greater sensitivity than standard microscopy, imagine the impact they would have on reducing the number of deaths worldwide from TB, especially in African nations where TB and HIV often co-occur, and access to health care is difficult.

APOPO’s project is a wonderful example of how simple innovations in science can have such a large footprint on global health. If you’re interested in learning more about APOPO, visit their website. You’ll find interesting videos and links to publications, plus ways to donate.

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