Rheum in Bloom

First the good news: According to a study commissioned by the Centers for Disease Control and Prevention and published in JAMA Pediatrics on Dec. 5, measles was officially eliminated in the United States in 2000, and that elimination persisted until 2011. This shows that the vaccine, first approved in 1963, has been effective at "eliminating" the disease, defined as the absence of endemic disease transmission.

This is no small feat. Measles is highly contagious, and prior to 1963, resulted in about 500 deaths per year in the United States, and tens of thousands of hospitalizations. Because it’s so highly contagious, vaccinating a large chunk of susceptible patients was the only way to effectively combat the disease. The "elimination" of the disease marks the success of vaccination strategies. Globally, there are now 500,000 fewer deaths per year from measles than there were a decade ago. If we continue with vaccination programs as we do, there is a chance we can eradicate the disease (JAMA Pediatrics 2013 [doi:10.1001/jamapediatrics.2013.4342]).

Now the bad news: This year, according to a statement that the CDC put out on Dec. 5, there have been 175 cases of measles. This is three times the annual median number of about 60. These cases have been concentrated in communities that are against vaccination, usually brought in from other places where antivaccination sentiments are also high, like Europe, or where vaccination strategies are lagging, like the developing world.

In a well-publicized outbreak in Texas in August, 21 unvaccinated people belonging to the Eagle Mountain International Church contracted the disease when an unvaccinated man travelled to Indonesia and came back ill. The pastor, Terri Copeland Pearsons, daughter of a televangelist Kenneth Copeland, clarifies that she is not against vaccinations but she has reservations about them. "The concerns we have had are primarily with very young children who have family history of autism and with bundling too many immunizations at one time."

Ms. Pearsons further says: "the facts are the facts, but then we know the truth. That always overcomes facts." When did fact become the enemy? How does faith trump science? Why do people treat science with such skepticism, and yet take anecdotes as gospel truth? How is it that despite the best efforts of infectious disease and pediatric societies to dispel such mistaken notions, these ideas survive?

In studies exploring the psychology of vaccine refusal, the factors that parents take into consideration include, but are not limited to, the perceptions of vulnerability of the children, severity of the disease, and safety of the vaccine.

People have forgotten just how severe measles can be. In addition, the unfounded belief that the vaccine can cause autism has just taken on a life of its own, given credibility by celebrities.

I understand that for some people anecdotes often tell a more powerful story than data does. So here’s one anecdote from the personal anecdote library of a doctor from a developing country.

I knew Albert through mutual friends. He played bass in a rock band, belonged to a fraternity in medical school, was involved in intramural basketball, and was in a loving relationship. By the time we graduated from medical school, he was the proud father of a baby girl.

But then things seemed to fall out of place. He failed the medical boards. He uncharacteristically sank into a deep depression that was so severe that he required inpatient treatment, and even then the treatments were not working. Still the assumption was that he had depression from his life’s circumstances.

And then he had a seizure.

That was when the diagnosis of subacute sclerosing panencephalitis, or SSPE, was made. It explained the personality change, intellectual difficulty, and seizures. He had contracted measles 10 years earlier, and this is a known complication of measles, one that hospitals in the Philippines are unfortunately all too familiar with. He died within a few weeks of diagnosis.

Society has forgotten how severe measles can be. We have an effective vaccine and effective global vaccination programs. We therefore have a chance to eradicate this disease altogether, like we did with smallpox and like we’re trying to do with polio. One parent’s strongly held but erroneous beliefs can cause trouble for large segments of the population. Ignoring the antivaccination rhetoric won’t make it go away.

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

First the good news: According to a study commissioned by the Centers for Disease Control and Prevention and published in JAMA Pediatrics on Dec. 5, measles was officially eliminated in the United States in 2000, and that elimination persisted until 2011. This shows that the vaccine, first approved in 1963, has been effective at "eliminating" the disease, defined as the absence of endemic disease transmission.

This is no small feat. Measles is highly contagious, and prior to 1963, resulted in about 500 deaths per year in the United States, and tens of thousands of hospitalizations. Because it’s so highly contagious, vaccinating a large chunk of susceptible patients was the only way to effectively combat the disease. The "elimination" of the disease marks the success of vaccination strategies. Globally, there are now 500,000 fewer deaths per year from measles than there were a decade ago. If we continue with vaccination programs as we do, there is a chance we can eradicate the disease (JAMA Pediatrics 2013 [doi:10.1001/jamapediatrics.2013.4342]).

Now the bad news: This year, according to a statement that the CDC put out on Dec. 5, there have been 175 cases of measles. This is three times the annual median number of about 60. These cases have been concentrated in communities that are against vaccination, usually brought in from other places where antivaccination sentiments are also high, like Europe, or where vaccination strategies are lagging, like the developing world.

In a well-publicized outbreak in Texas in August, 21 unvaccinated people belonging to the Eagle Mountain International Church contracted the disease when an unvaccinated man travelled to Indonesia and came back ill. The pastor, Terri Copeland Pearsons, daughter of a televangelist Kenneth Copeland, clarifies that she is not against vaccinations but she has reservations about them. "The concerns we have had are primarily with very young children who have family history of autism and with bundling too many immunizations at one time."

Ms. Pearsons further says: "the facts are the facts, but then we know the truth. That always overcomes facts." When did fact become the enemy? How does faith trump science? Why do people treat science with such skepticism, and yet take anecdotes as gospel truth? How is it that despite the best efforts of infectious disease and pediatric societies to dispel such mistaken notions, these ideas survive?

In studies exploring the psychology of vaccine refusal, the factors that parents take into consideration include, but are not limited to, the perceptions of vulnerability of the children, severity of the disease, and safety of the vaccine.

People have forgotten just how severe measles can be. In addition, the unfounded belief that the vaccine can cause autism has just taken on a life of its own, given credibility by celebrities.

I understand that for some people anecdotes often tell a more powerful story than data does. So here’s one anecdote from the personal anecdote library of a doctor from a developing country.

I knew Albert through mutual friends. He played bass in a rock band, belonged to a fraternity in medical school, was involved in intramural basketball, and was in a loving relationship. By the time we graduated from medical school, he was the proud father of a baby girl.

But then things seemed to fall out of place. He failed the medical boards. He uncharacteristically sank into a deep depression that was so severe that he required inpatient treatment, and even then the treatments were not working. Still the assumption was that he had depression from his life’s circumstances.

And then he had a seizure.

That was when the diagnosis of subacute sclerosing panencephalitis, or SSPE, was made. It explained the personality change, intellectual difficulty, and seizures. He had contracted measles 10 years earlier, and this is a known complication of measles, one that hospitals in the Philippines are unfortunately all too familiar with. He died within a few weeks of diagnosis.

Society has forgotten how severe measles can be. We have an effective vaccine and effective global vaccination programs. We therefore have a chance to eradicate this disease altogether, like we did with smallpox and like we’re trying to do with polio. One parent’s strongly held but erroneous beliefs can cause trouble for large segments of the population. Ignoring the antivaccination rhetoric won’t make it go away.

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

First the good news: According to a study commissioned by the Centers for Disease Control and Prevention and published in JAMA Pediatrics on Dec. 5, measles was officially eliminated in the United States in 2000, and that elimination persisted until 2011. This shows that the vaccine, first approved in 1963, has been effective at "eliminating" the disease, defined as the absence of endemic disease transmission.

This is no small feat. Measles is highly contagious, and prior to 1963, resulted in about 500 deaths per year in the United States, and tens of thousands of hospitalizations. Because it’s so highly contagious, vaccinating a large chunk of susceptible patients was the only way to effectively combat the disease. The "elimination" of the disease marks the success of vaccination strategies. Globally, there are now 500,000 fewer deaths per year from measles than there were a decade ago. If we continue with vaccination programs as we do, there is a chance we can eradicate the disease (JAMA Pediatrics 2013 [doi:10.1001/jamapediatrics.2013.4342]).

Now the bad news: This year, according to a statement that the CDC put out on Dec. 5, there have been 175 cases of measles. This is three times the annual median number of about 60. These cases have been concentrated in communities that are against vaccination, usually brought in from other places where antivaccination sentiments are also high, like Europe, or where vaccination strategies are lagging, like the developing world.

In a well-publicized outbreak in Texas in August, 21 unvaccinated people belonging to the Eagle Mountain International Church contracted the disease when an unvaccinated man travelled to Indonesia and came back ill. The pastor, Terri Copeland Pearsons, daughter of a televangelist Kenneth Copeland, clarifies that she is not against vaccinations but she has reservations about them. "The concerns we have had are primarily with very young children who have family history of autism and with bundling too many immunizations at one time."

Ms. Pearsons further says: "the facts are the facts, but then we know the truth. That always overcomes facts." When did fact become the enemy? How does faith trump science? Why do people treat science with such skepticism, and yet take anecdotes as gospel truth? How is it that despite the best efforts of infectious disease and pediatric societies to dispel such mistaken notions, these ideas survive?

In studies exploring the psychology of vaccine refusal, the factors that parents take into consideration include, but are not limited to, the perceptions of vulnerability of the children, severity of the disease, and safety of the vaccine.

People have forgotten just how severe measles can be. In addition, the unfounded belief that the vaccine can cause autism has just taken on a life of its own, given credibility by celebrities.

I understand that for some people anecdotes often tell a more powerful story than data does. So here’s one anecdote from the personal anecdote library of a doctor from a developing country.

I knew Albert through mutual friends. He played bass in a rock band, belonged to a fraternity in medical school, was involved in intramural basketball, and was in a loving relationship. By the time we graduated from medical school, he was the proud father of a baby girl.

But then things seemed to fall out of place. He failed the medical boards. He uncharacteristically sank into a deep depression that was so severe that he required inpatient treatment, and even then the treatments were not working. Still the assumption was that he had depression from his life’s circumstances.

And then he had a seizure.

That was when the diagnosis of subacute sclerosing panencephalitis, or SSPE, was made. It explained the personality change, intellectual difficulty, and seizures. He had contracted measles 10 years earlier, and this is a known complication of measles, one that hospitals in the Philippines are unfortunately all too familiar with. He died within a few weeks of diagnosis.

Society has forgotten how severe measles can be. We have an effective vaccine and effective global vaccination programs. We therefore have a chance to eradicate this disease altogether, like we did with smallpox and like we’re trying to do with polio. One parent’s strongly held but erroneous beliefs can cause trouble for large segments of the population. Ignoring the antivaccination rhetoric won’t make it go away.

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

A month ago, all five physicians in our practice received notice that we would no longer be covered under UnitedHealthcare Medicare Advantage plans. No reason was given, nor had we been given any kind of advanced notice that this was even a possibility. This was based on our business tax ID number, by the way, not on any individual doctor’s credentials. Very quickly it became evident that this was part of a 20%-30% reduction in their physician panels in multiple states, including Rhode Island, Connecticut, New York, New Jersey, Florida, Indiana, and Ohio.

What hasn’t been so easy to figure out is why. The insurance giant has not been forthcoming about the decision. In an advertisement in the Providence Journal, they cited "severe funding reductions for Medicare Advantage Plans."

Medicare Advantage Plans are Medicare plans that are administered by private insurance companies. They contract with the government to administer Medicare, and patients also pay a premium, making it profitable for insurers. These plans, however, are more expensive for the federal government, and in an effort to curtail the burgeoning cost of health care, "companies that don’t use 80% to 85% of revenues on care are forced to issue rebates to members for the difference," according to financial services company The Motley Fool.

In addition, there have been proposed rate cuts to Medicare Advantage Plans, in part to offset the cost of expanding Medicaid as the Affordable Care Act mandates. The Associated Press reported that UnitedHealthcare stock did not perform as expected in the third quarter of 2013. UnitedHealthcare blamed this on the rate cuts that the federal government imposed on Medicare.

So perhaps the Medicare Advantage Plans are not as profitable for the company as they once were, as the aforementioned advertisement in the Providence Journal implied. That does not explain the reduction of 20%-30% of their providers, though.

In a statement to the Hartford Courant, Dennis O’Brien, regional president of UnitedHealthcare Networks, had this to say: "We are assessing our network in Connecticut to help us provide higher quality and more affordable health care coverage for Medicare beneficiaries."

That explains nothing at all. It implies that the physicians they removed from their roster were of inferior quality and were costing them more money. And yet they have not given any explanation for what these "higher quality and more affordable" standards are. Furthermore, if quality and cost were the real issue, why would we be appropriate for UnitedHealthcare commercial patients but not for Medicare patients?

There has been a lot of speculation about why UnitedHealthcare is doing this, but until the company is more forthcoming, or is forced to account for its behavior (by subscribers or by politicians), we won’t really know.

In the meantime, the company’s unilateral decision will leave thousands of patients across states with interrupted medical care. It will take time for these patients to find new doctors, establish care, and build rapport.

If there is anything that’s become clearer to me from this debacle, it is this: We doctors hold ourselves accountable to our patients, but UnitedHealthcare, and maybe other private insurers as well, is accountable only to its shareholders.

In the debate over universal health care, health care is repeatedly referred to as a commodity that is malleable according to market forces. But this is a false equivalence, is it not? Chief Justice John Roberts’ preference for broccoli may be subject to supply and demand, but your right to health care should not be. That narrative needs to be reframed if people’s health and well-being are ever to trump the investors’ bottom line.

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

A month ago, all five physicians in our practice received notice that we would no longer be covered under UnitedHealthcare Medicare Advantage plans. No reason was given, nor had we been given any kind of advanced notice that this was even a possibility. This was based on our business tax ID number, by the way, not on any individual doctor’s credentials. Very quickly it became evident that this was part of a 20%-30% reduction in their physician panels in multiple states, including Rhode Island, Connecticut, New York, New Jersey, Florida, Indiana, and Ohio.

What hasn’t been so easy to figure out is why. The insurance giant has not been forthcoming about the decision. In an advertisement in the Providence Journal, they cited "severe funding reductions for Medicare Advantage Plans."

Medicare Advantage Plans are Medicare plans that are administered by private insurance companies. They contract with the government to administer Medicare, and patients also pay a premium, making it profitable for insurers. These plans, however, are more expensive for the federal government, and in an effort to curtail the burgeoning cost of health care, "companies that don’t use 80% to 85% of revenues on care are forced to issue rebates to members for the difference," according to financial services company The Motley Fool.

In addition, there have been proposed rate cuts to Medicare Advantage Plans, in part to offset the cost of expanding Medicaid as the Affordable Care Act mandates. The Associated Press reported that UnitedHealthcare stock did not perform as expected in the third quarter of 2013. UnitedHealthcare blamed this on the rate cuts that the federal government imposed on Medicare.

So perhaps the Medicare Advantage Plans are not as profitable for the company as they once were, as the aforementioned advertisement in the Providence Journal implied. That does not explain the reduction of 20%-30% of their providers, though.

In a statement to the Hartford Courant, Dennis O’Brien, regional president of UnitedHealthcare Networks, had this to say: "We are assessing our network in Connecticut to help us provide higher quality and more affordable health care coverage for Medicare beneficiaries."

That explains nothing at all. It implies that the physicians they removed from their roster were of inferior quality and were costing them more money. And yet they have not given any explanation for what these "higher quality and more affordable" standards are. Furthermore, if quality and cost were the real issue, why would we be appropriate for UnitedHealthcare commercial patients but not for Medicare patients?

There has been a lot of speculation about why UnitedHealthcare is doing this, but until the company is more forthcoming, or is forced to account for its behavior (by subscribers or by politicians), we won’t really know.

In the meantime, the company’s unilateral decision will leave thousands of patients across states with interrupted medical care. It will take time for these patients to find new doctors, establish care, and build rapport.

If there is anything that’s become clearer to me from this debacle, it is this: We doctors hold ourselves accountable to our patients, but UnitedHealthcare, and maybe other private insurers as well, is accountable only to its shareholders.

In the debate over universal health care, health care is repeatedly referred to as a commodity that is malleable according to market forces. But this is a false equivalence, is it not? Chief Justice John Roberts’ preference for broccoli may be subject to supply and demand, but your right to health care should not be. That narrative needs to be reframed if people’s health and well-being are ever to trump the investors’ bottom line.

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

A month ago, all five physicians in our practice received notice that we would no longer be covered under UnitedHealthcare Medicare Advantage plans. No reason was given, nor had we been given any kind of advanced notice that this was even a possibility. This was based on our business tax ID number, by the way, not on any individual doctor’s credentials. Very quickly it became evident that this was part of a 20%-30% reduction in their physician panels in multiple states, including Rhode Island, Connecticut, New York, New Jersey, Florida, Indiana, and Ohio.

What hasn’t been so easy to figure out is why. The insurance giant has not been forthcoming about the decision. In an advertisement in the Providence Journal, they cited "severe funding reductions for Medicare Advantage Plans."

Medicare Advantage Plans are Medicare plans that are administered by private insurance companies. They contract with the government to administer Medicare, and patients also pay a premium, making it profitable for insurers. These plans, however, are more expensive for the federal government, and in an effort to curtail the burgeoning cost of health care, "companies that don’t use 80% to 85% of revenues on care are forced to issue rebates to members for the difference," according to financial services company The Motley Fool.

In addition, there have been proposed rate cuts to Medicare Advantage Plans, in part to offset the cost of expanding Medicaid as the Affordable Care Act mandates. The Associated Press reported that UnitedHealthcare stock did not perform as expected in the third quarter of 2013. UnitedHealthcare blamed this on the rate cuts that the federal government imposed on Medicare.

So perhaps the Medicare Advantage Plans are not as profitable for the company as they once were, as the aforementioned advertisement in the Providence Journal implied. That does not explain the reduction of 20%-30% of their providers, though.

In a statement to the Hartford Courant, Dennis O’Brien, regional president of UnitedHealthcare Networks, had this to say: "We are assessing our network in Connecticut to help us provide higher quality and more affordable health care coverage for Medicare beneficiaries."

That explains nothing at all. It implies that the physicians they removed from their roster were of inferior quality and were costing them more money. And yet they have not given any explanation for what these "higher quality and more affordable" standards are. Furthermore, if quality and cost were the real issue, why would we be appropriate for UnitedHealthcare commercial patients but not for Medicare patients?

There has been a lot of speculation about why UnitedHealthcare is doing this, but until the company is more forthcoming, or is forced to account for its behavior (by subscribers or by politicians), we won’t really know.

In the meantime, the company’s unilateral decision will leave thousands of patients across states with interrupted medical care. It will take time for these patients to find new doctors, establish care, and build rapport.

If there is anything that’s become clearer to me from this debacle, it is this: We doctors hold ourselves accountable to our patients, but UnitedHealthcare, and maybe other private insurers as well, is accountable only to its shareholders.

In the debate over universal health care, health care is repeatedly referred to as a commodity that is malleable according to market forces. But this is a false equivalence, is it not? Chief Justice John Roberts’ preference for broccoli may be subject to supply and demand, but your right to health care should not be. That narrative needs to be reframed if people’s health and well-being are ever to trump the investors’ bottom line.

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

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

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

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

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

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

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

Many of my patients come in having already looked up their symptoms. Frequently, this admission is accompanied by a mumbled apology, an acknowledgment that doctors "hate that."

I do not disapprove of patients looking up their symptoms at all. I find that their online forays only enrich the discussion because they are prepared for the meeting and have excellent questions. I appreciate their curiosity; it serves the pedant in me well. Not only do I get to explain what is not clear, I also get to correct misinformation.

It also indicates a sense of ownership, participation rather than passivity. The patients are engaged in coming up with a treatment plan, and hopefully this translates into compliance. Patients have asked about dietary modifications for their gout, pool exercises for their osteoarthritis, or the wisdom of biologic treatments in light of their past breast cancer. I think it provides patients with a sense of some degree, however small, of control over their disease and its treatment.

But not all information is created equal, and I think some information may be more fraught for a nonmedical consumer.

At the moment, there are some electronic health record (EHR) software programs that give patients access to some lab results. This can be quite handy; for example, I’ve been saved the trouble of interrupting a patient visit to track down lab results because the patient could access the results using his smartphone.

But it can be pernicious, too. The fine art of medicine does not always lend itself to discrete labeling. Think of all the slightly elevated creatine kinases, erythrocyte sedimentation rates, and antinuclear antibodies that you encounter daily, as well as the training that you went through to understand what to do with these mildly abnormal labs. For all our focus on evidence-based medicine, there is a great deal of nuance to what we do, and nominal "normal" vs "abnormal" results can be misleading at best and anxiety-provoking at worst.

In addition, we may someday be required to allow patients to see office notes. Already I’ve received a handful of angry phone calls from patients because they got a copy of my note. One patient was mad because he thought I called him anorexic (he calmed down when I explained what anorexia meant). Another patient was angry because I used obesity as a diagnosis (she, on the other hand, did not calm down at all). I had a patient come in for her follow-up visit with a copy of my first note, which she had very heavily annotated with details that were irrelevant in a medical context, demanding that I modify my first note.

You may have heard of the study published last October in the Annals of Internal Medicine (2012;157:461-70), in which 105 doctors in three different health care systems allowed more than 13,000 patients to read their notes for a year. Overall, the results were not bad. Doctors felt that it improved transparency and shared decision making, and patients agreed that it fostered trust.

But a minority of patients did report feeling anxious or offended. One out of three felt that they ought to be able to approve the note. And doctors reported having to modify their note – not discussing alternative diagnoses, for example, or not being as candid about obesity. Which belies the idea that the system "improved transparency," no?

I have an old mentor who used to say that in order for consent to be truly informed, the patient should have also gone to medical school. If we are being frank, we ought to admit that there are limits to what a patient can understand, and full disclosure may not be always be appropriate.

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

Many of my patients come in having already looked up their symptoms. Frequently, this admission is accompanied by a mumbled apology, an acknowledgment that doctors "hate that."

I do not disapprove of patients looking up their symptoms at all. I find that their online forays only enrich the discussion because they are prepared for the meeting and have excellent questions. I appreciate their curiosity; it serves the pedant in me well. Not only do I get to explain what is not clear, I also get to correct misinformation.

It also indicates a sense of ownership, participation rather than passivity. The patients are engaged in coming up with a treatment plan, and hopefully this translates into compliance. Patients have asked about dietary modifications for their gout, pool exercises for their osteoarthritis, or the wisdom of biologic treatments in light of their past breast cancer. I think it provides patients with a sense of some degree, however small, of control over their disease and its treatment.

But not all information is created equal, and I think some information may be more fraught for a nonmedical consumer.

At the moment, there are some electronic health record (EHR) software programs that give patients access to some lab results. This can be quite handy; for example, I’ve been saved the trouble of interrupting a patient visit to track down lab results because the patient could access the results using his smartphone.

But it can be pernicious, too. The fine art of medicine does not always lend itself to discrete labeling. Think of all the slightly elevated creatine kinases, erythrocyte sedimentation rates, and antinuclear antibodies that you encounter daily, as well as the training that you went through to understand what to do with these mildly abnormal labs. For all our focus on evidence-based medicine, there is a great deal of nuance to what we do, and nominal "normal" vs "abnormal" results can be misleading at best and anxiety-provoking at worst.

In addition, we may someday be required to allow patients to see office notes. Already I’ve received a handful of angry phone calls from patients because they got a copy of my note. One patient was mad because he thought I called him anorexic (he calmed down when I explained what anorexia meant). Another patient was angry because I used obesity as a diagnosis (she, on the other hand, did not calm down at all). I had a patient come in for her follow-up visit with a copy of my first note, which she had very heavily annotated with details that were irrelevant in a medical context, demanding that I modify my first note.

You may have heard of the study published last October in the Annals of Internal Medicine (2012;157:461-70), in which 105 doctors in three different health care systems allowed more than 13,000 patients to read their notes for a year. Overall, the results were not bad. Doctors felt that it improved transparency and shared decision making, and patients agreed that it fostered trust.

But a minority of patients did report feeling anxious or offended. One out of three felt that they ought to be able to approve the note. And doctors reported having to modify their note – not discussing alternative diagnoses, for example, or not being as candid about obesity. Which belies the idea that the system "improved transparency," no?

I have an old mentor who used to say that in order for consent to be truly informed, the patient should have also gone to medical school. If we are being frank, we ought to admit that there are limits to what a patient can understand, and full disclosure may not be always be appropriate.

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

Many of my patients come in having already looked up their symptoms. Frequently, this admission is accompanied by a mumbled apology, an acknowledgment that doctors "hate that."

I do not disapprove of patients looking up their symptoms at all. I find that their online forays only enrich the discussion because they are prepared for the meeting and have excellent questions. I appreciate their curiosity; it serves the pedant in me well. Not only do I get to explain what is not clear, I also get to correct misinformation.

It also indicates a sense of ownership, participation rather than passivity. The patients are engaged in coming up with a treatment plan, and hopefully this translates into compliance. Patients have asked about dietary modifications for their gout, pool exercises for their osteoarthritis, or the wisdom of biologic treatments in light of their past breast cancer. I think it provides patients with a sense of some degree, however small, of control over their disease and its treatment.

But not all information is created equal, and I think some information may be more fraught for a nonmedical consumer.

At the moment, there are some electronic health record (EHR) software programs that give patients access to some lab results. This can be quite handy; for example, I’ve been saved the trouble of interrupting a patient visit to track down lab results because the patient could access the results using his smartphone.

But it can be pernicious, too. The fine art of medicine does not always lend itself to discrete labeling. Think of all the slightly elevated creatine kinases, erythrocyte sedimentation rates, and antinuclear antibodies that you encounter daily, as well as the training that you went through to understand what to do with these mildly abnormal labs. For all our focus on evidence-based medicine, there is a great deal of nuance to what we do, and nominal "normal" vs "abnormal" results can be misleading at best and anxiety-provoking at worst.

In addition, we may someday be required to allow patients to see office notes. Already I’ve received a handful of angry phone calls from patients because they got a copy of my note. One patient was mad because he thought I called him anorexic (he calmed down when I explained what anorexia meant). Another patient was angry because I used obesity as a diagnosis (she, on the other hand, did not calm down at all). I had a patient come in for her follow-up visit with a copy of my first note, which she had very heavily annotated with details that were irrelevant in a medical context, demanding that I modify my first note.

You may have heard of the study published last October in the Annals of Internal Medicine (2012;157:461-70), in which 105 doctors in three different health care systems allowed more than 13,000 patients to read their notes for a year. Overall, the results were not bad. Doctors felt that it improved transparency and shared decision making, and patients agreed that it fostered trust.

But a minority of patients did report feeling anxious or offended. One out of three felt that they ought to be able to approve the note. And doctors reported having to modify their note – not discussing alternative diagnoses, for example, or not being as candid about obesity. Which belies the idea that the system "improved transparency," no?

I have an old mentor who used to say that in order for consent to be truly informed, the patient should have also gone to medical school. If we are being frank, we ought to admit that there are limits to what a patient can understand, and full disclosure may not be always be appropriate.

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

I’d known Jerry for over a year. When I first met him it was because he had gotten admitted with fevers and an elevation in his erythrocyte sedimentation rate. In the absence of an obvious infectious cause, I was called to see him.

He was such a character. His intelligence was evident. The day that I met him he told me that he was a retired journalist, and that he planned to write a book. His subject was to be one of the presidents, as he had a real interest in history. I particularly enjoyed hearing his "This I Believe" essay on Rhode Island’s National Public Radio about how people these days get so attached to material things, and how far removed this reality is from how he grew up.

He was feisty and opinionated. He, like many other elderly men, thought he knew best, and told everyone – doctors, nurses, his wife – how to do their jobs. He fired his primary care doctor because the doctor told him he couldn’t drive anymore. He stopped his Coumadin because he established, "after applying the scientific method" (i.e., having rechallenged himself with it), that it caused severe pruritis that he just was not willing to put up with.

In the winter of 2012, he developed what seemed to be new-onset Raynaud’s, coincident with a worsening of his thrombocytopenia and anemia. His blood pressure was too low for him to tolerate a calcium channel blocker. I suggested sildenafil, but it was not until mid-June that he came to me asking to be put on it because the condition had progressed quite rapidly, he had developed ulcerations, and he was in a lot of pain. By then we knew about the non-Hodgkin’s lymphoma on top of his preexisting myelodysplastic syndrome, and he was about to get a second opinion about getting a second bone-marrow biopsy at Dana-Farber Cancer Institute.

After the inevitable battle for insurance coverage, we managed to get the sildenafil approved for him, and it made such a huge difference that on July 26, he wrote me, by snail mail, a letter of gratitude: "The lesions are slowly vanishing, the ailing fingernails are taking deeper breaths and thickening, the fingertips are getting firmer. Your compassion, skill, and determination to aid your patients have defeated dis-ease." No doubt he really meant dis-ease, as he repeated the unusual formulation later on. He had such a way with words.

"I looked forward to another winter here with horror. But, thanks to your determination to help ... I am canceling my plans to escape to Florida."

He ended the letter with an invitation to take me to my favorite dim sum restaurant in Providence that I had recommended to him and that he liked as much as I did. He planned on taking me there in mid-August. "I don’t believe that Hippocrates would scorn such an invitation. Let me show off my fingers!"

This was not the first time that he’d invited me to dim sum, but it was the first time that I actually considered accepting the offer, having been granted imaginary permission by Hippocrates.

Jerry passed away on Aug. 1. I was too late for dim sum.

"My soul is from elsewhere, I am sure of that. And I intend to end up there." –Rumi

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

I’d known Jerry for over a year. When I first met him it was because he had gotten admitted with fevers and an elevation in his erythrocyte sedimentation rate. In the absence of an obvious infectious cause, I was called to see him.

He was such a character. His intelligence was evident. The day that I met him he told me that he was a retired journalist, and that he planned to write a book. His subject was to be one of the presidents, as he had a real interest in history. I particularly enjoyed hearing his "This I Believe" essay on Rhode Island’s National Public Radio about how people these days get so attached to material things, and how far removed this reality is from how he grew up.

He was feisty and opinionated. He, like many other elderly men, thought he knew best, and told everyone – doctors, nurses, his wife – how to do their jobs. He fired his primary care doctor because the doctor told him he couldn’t drive anymore. He stopped his Coumadin because he established, "after applying the scientific method" (i.e., having rechallenged himself with it), that it caused severe pruritis that he just was not willing to put up with.

In the winter of 2012, he developed what seemed to be new-onset Raynaud’s, coincident with a worsening of his thrombocytopenia and anemia. His blood pressure was too low for him to tolerate a calcium channel blocker. I suggested sildenafil, but it was not until mid-June that he came to me asking to be put on it because the condition had progressed quite rapidly, he had developed ulcerations, and he was in a lot of pain. By then we knew about the non-Hodgkin’s lymphoma on top of his preexisting myelodysplastic syndrome, and he was about to get a second opinion about getting a second bone-marrow biopsy at Dana-Farber Cancer Institute.

After the inevitable battle for insurance coverage, we managed to get the sildenafil approved for him, and it made such a huge difference that on July 26, he wrote me, by snail mail, a letter of gratitude: "The lesions are slowly vanishing, the ailing fingernails are taking deeper breaths and thickening, the fingertips are getting firmer. Your compassion, skill, and determination to aid your patients have defeated dis-ease." No doubt he really meant dis-ease, as he repeated the unusual formulation later on. He had such a way with words.

"I looked forward to another winter here with horror. But, thanks to your determination to help ... I am canceling my plans to escape to Florida."

He ended the letter with an invitation to take me to my favorite dim sum restaurant in Providence that I had recommended to him and that he liked as much as I did. He planned on taking me there in mid-August. "I don’t believe that Hippocrates would scorn such an invitation. Let me show off my fingers!"

This was not the first time that he’d invited me to dim sum, but it was the first time that I actually considered accepting the offer, having been granted imaginary permission by Hippocrates.

Jerry passed away on Aug. 1. I was too late for dim sum.

"My soul is from elsewhere, I am sure of that. And I intend to end up there." –Rumi

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

I’d known Jerry for over a year. When I first met him it was because he had gotten admitted with fevers and an elevation in his erythrocyte sedimentation rate. In the absence of an obvious infectious cause, I was called to see him.

He was such a character. His intelligence was evident. The day that I met him he told me that he was a retired journalist, and that he planned to write a book. His subject was to be one of the presidents, as he had a real interest in history. I particularly enjoyed hearing his "This I Believe" essay on Rhode Island’s National Public Radio about how people these days get so attached to material things, and how far removed this reality is from how he grew up.

He was feisty and opinionated. He, like many other elderly men, thought he knew best, and told everyone – doctors, nurses, his wife – how to do their jobs. He fired his primary care doctor because the doctor told him he couldn’t drive anymore. He stopped his Coumadin because he established, "after applying the scientific method" (i.e., having rechallenged himself with it), that it caused severe pruritis that he just was not willing to put up with.

In the winter of 2012, he developed what seemed to be new-onset Raynaud’s, coincident with a worsening of his thrombocytopenia and anemia. His blood pressure was too low for him to tolerate a calcium channel blocker. I suggested sildenafil, but it was not until mid-June that he came to me asking to be put on it because the condition had progressed quite rapidly, he had developed ulcerations, and he was in a lot of pain. By then we knew about the non-Hodgkin’s lymphoma on top of his preexisting myelodysplastic syndrome, and he was about to get a second opinion about getting a second bone-marrow biopsy at Dana-Farber Cancer Institute.

After the inevitable battle for insurance coverage, we managed to get the sildenafil approved for him, and it made such a huge difference that on July 26, he wrote me, by snail mail, a letter of gratitude: "The lesions are slowly vanishing, the ailing fingernails are taking deeper breaths and thickening, the fingertips are getting firmer. Your compassion, skill, and determination to aid your patients have defeated dis-ease." No doubt he really meant dis-ease, as he repeated the unusual formulation later on. He had such a way with words.

"I looked forward to another winter here with horror. But, thanks to your determination to help ... I am canceling my plans to escape to Florida."

He ended the letter with an invitation to take me to my favorite dim sum restaurant in Providence that I had recommended to him and that he liked as much as I did. He planned on taking me there in mid-August. "I don’t believe that Hippocrates would scorn such an invitation. Let me show off my fingers!"

This was not the first time that he’d invited me to dim sum, but it was the first time that I actually considered accepting the offer, having been granted imaginary permission by Hippocrates.

Jerry passed away on Aug. 1. I was too late for dim sum.

"My soul is from elsewhere, I am sure of that. And I intend to end up there." –Rumi

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

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

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

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

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

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

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

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

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

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

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

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

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

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.

There was an article in the New York Times recently about a software program developed by scientists at Harvard University and the Massachusetts Institute of Technology that grades essays instantly. How strange it must be to have a computer judge all the nuances of language involved in a work of prose. Multiple-choice questions alone can already be contentious, as anyone can attest who has waited months for the results of a 240-question board exam.

It gets even more hairy in real life. What I would give for the ability to examine a patient, submit my findings to some omniscient entity (Watson, maybe?), and get instant feedback.

Unfortunately, this is not how rheumatology works. The temporal artery biopsy does not always come back positive, and when it doesn’t, it becomes much harder to know what to do when a patient relapses once he is down to 20 mg of prednisone. And how do I justify putting a refractory dermatomyositis patient on a toxic immunosuppressant when her muscle biopsy is negative and all I have to base my decision on is a highly suggestive skin rash?

Very little of what we do as rheumatologists is evidence based. Doubt is a recurring theme in my practice. I am lucky that I practice with other physicians with whom I can bounce ideas around and that I maintain a relationship with previous mentors who are always ready with good advice. I am fortunate to be close enough to Boston that many of my scleroderma patients can get enrolled in trials. But doubt is ever-present and is very frequently the cause of not insignificant personal malaise.

Here’s what’s even more striking about the essay-grading software, and even more pertinent to our nebulous field: they’ve eliminated waiting. According to the Times article, a student can submit an essay, receive feedback right away, and resubmit the essay in an attempt to get a better grade. That is an enviable state of affairs.

There is, however, something to be said for waiting. Patience is a defining virtue in rheumatology. We wait for a patient with vague symptoms to develop more symptoms or to "declare" themselves. We wait for labs and pathology reports and imaging findings. Perhaps most importantly, we wait for either a response to treatment or for the other shoe to drop.

By promising instant feedback to students, are we not depriving them of an important life lesson? After all, we spend our lifetimes waiting. We wait to grow up, to get our driver’s licenses, to hear about school or job applications. We eagerly wait for holidays, for meals to be served, and for spring to arrive. We wait to grow older. We wait to recover from illness.

As Father James Donelan, S.J., put it, "Waiting is a mystery – a natural sacrament of life." Waiting teaches us to have patience and self-control, to innovate and be imaginative. Waiting feeds our curiosity and cultivates a sense of wonder.

There is something to be said for learning to be comfortable with disquiet. Through doubt and waiting we learn to ask questions. And in a field like ours, where our scope of knowledge is so tiny compared with what we have yet to learn, questioning is not a bad word. Vladimir Nabokov, who was also an entomologist apart from being a writer, said it best: "There is no science without fancy and no art without fact."

Dr. Chan practices rheumatology in Pawtucket, R.I. This column, "Rheum in Bloom," appears regularly in Rheumatology News.

One of the pleasures of a busy outpatient practice is the privilege of meeting a wide variety of people. Perhaps my imagination is limited, but I can’t think of any other profession where one gets to interact in a meaningful way with a different person every 15 minutes.

Although the work of listening to patients tell me what ails them can be mentally and emotionally exhausting, there are unquantifiable rewards of getting to know so many different people. It might be a weakness on my part, but I get attached to my patients and frequently find myself quite invested in their well-being.

It helps that I practice in a small city with many universities and only a handful of rheumatologists. I have met judges and lawyers, restaurant managers, social workers, mail carriers, firefighters, politicians, strippers, local news meteorologists, jewelry makers, religious studies professors, radio talk show hosts, biotech rising stars, artists, 90-year-old ski instructors, and professional tennis players (something called court tennis, which is different from tennis as we know it but is apparently the game from which all racquet sports evolve). The list goes on.

I’ve met people from all over the world. There are Thai, Hmong, Laotian, and Vietnamese patients. There are those from Colombia, Peru, and Brazil. There are Nigerians and South Africans and Botswanans and Liberians (one of whom used to be good friends with ousted dictator Charles Taylor). I have a number of Greek, Italian, French, British, Spanish, and Portuguese patients, but most European transplants here are from the Azores.

A recent favorite is an accountant from Eritrea. He left Eritrea in the 1970s before Eritrea was even officially a country. In talking about his country’s history, he asked me this provocative question: "What have you heard about Eritrea?" What he really meant was that the country is run by a dictator who holds a tight reign over the media, so the outside world knows nothing about the corruption, human rights abuses, and political repression that occurs there.

That question got me thinking about how insular our lives can be, and how fortunate we are to have patients who enrich us by honoring us with their stories.

I’ve heard stories as dramatic as witnessing the slaughter of one’s family at the hands of the Khmer Rouge, or as mundane as teaching a son to make "adult decisions" in his senior year of college. I’ve heard stories of love and loss, of triumph and defeat, of gratitude and grace. Each encounter is a treasure, a distillation of the repository of wisdom that these unique individuals are. The experience is at once gratifying and humbling.

So I may be tired, and I may lose a bit of myself by becoming so attached to my patients, but I can’t think of anything I would rather be doing than being a doctor.

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

One of the pleasures of a busy outpatient practice is the privilege of meeting a wide variety of people. Perhaps my imagination is limited, but I can’t think of any other profession where one gets to interact in a meaningful way with a different person every 15 minutes.

Although the work of listening to patients tell me what ails them can be mentally and emotionally exhausting, there are unquantifiable rewards of getting to know so many different people. It might be a weakness on my part, but I get attached to my patients and frequently find myself quite invested in their well-being.

It helps that I practice in a small city with many universities and only a handful of rheumatologists. I have met judges and lawyers, restaurant managers, social workers, mail carriers, firefighters, politicians, strippers, local news meteorologists, jewelry makers, religious studies professors, radio talk show hosts, biotech rising stars, artists, 90-year-old ski instructors, and professional tennis players (something called court tennis, which is different from tennis as we know it but is apparently the game from which all racquet sports evolve). The list goes on.

I’ve met people from all over the world. There are Thai, Hmong, Laotian, and Vietnamese patients. There are those from Colombia, Peru, and Brazil. There are Nigerians and South Africans and Botswanans and Liberians (one of whom used to be good friends with ousted dictator Charles Taylor). I have a number of Greek, Italian, French, British, Spanish, and Portuguese patients, but most European transplants here are from the Azores.

A recent favorite is an accountant from Eritrea. He left Eritrea in the 1970s before Eritrea was even officially a country. In talking about his country’s history, he asked me this provocative question: "What have you heard about Eritrea?" What he really meant was that the country is run by a dictator who holds a tight reign over the media, so the outside world knows nothing about the corruption, human rights abuses, and political repression that occurs there.

That question got me thinking about how insular our lives can be, and how fortunate we are to have patients who enrich us by honoring us with their stories.

I’ve heard stories as dramatic as witnessing the slaughter of one’s family at the hands of the Khmer Rouge, or as mundane as teaching a son to make "adult decisions" in his senior year of college. I’ve heard stories of love and loss, of triumph and defeat, of gratitude and grace. Each encounter is a treasure, a distillation of the repository of wisdom that these unique individuals are. The experience is at once gratifying and humbling.

So I may be tired, and I may lose a bit of myself by becoming so attached to my patients, but I can’t think of anything I would rather be doing than being a doctor.

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

One of the pleasures of a busy outpatient practice is the privilege of meeting a wide variety of people. Perhaps my imagination is limited, but I can’t think of any other profession where one gets to interact in a meaningful way with a different person every 15 minutes.

Although the work of listening to patients tell me what ails them can be mentally and emotionally exhausting, there are unquantifiable rewards of getting to know so many different people. It might be a weakness on my part, but I get attached to my patients and frequently find myself quite invested in their well-being.

It helps that I practice in a small city with many universities and only a handful of rheumatologists. I have met judges and lawyers, restaurant managers, social workers, mail carriers, firefighters, politicians, strippers, local news meteorologists, jewelry makers, religious studies professors, radio talk show hosts, biotech rising stars, artists, 90-year-old ski instructors, and professional tennis players (something called court tennis, which is different from tennis as we know it but is apparently the game from which all racquet sports evolve). The list goes on.

I’ve met people from all over the world. There are Thai, Hmong, Laotian, and Vietnamese patients. There are those from Colombia, Peru, and Brazil. There are Nigerians and South Africans and Botswanans and Liberians (one of whom used to be good friends with ousted dictator Charles Taylor). I have a number of Greek, Italian, French, British, Spanish, and Portuguese patients, but most European transplants here are from the Azores.

A recent favorite is an accountant from Eritrea. He left Eritrea in the 1970s before Eritrea was even officially a country. In talking about his country’s history, he asked me this provocative question: "What have you heard about Eritrea?" What he really meant was that the country is run by a dictator who holds a tight reign over the media, so the outside world knows nothing about the corruption, human rights abuses, and political repression that occurs there.

That question got me thinking about how insular our lives can be, and how fortunate we are to have patients who enrich us by honoring us with their stories.

I’ve heard stories as dramatic as witnessing the slaughter of one’s family at the hands of the Khmer Rouge, or as mundane as teaching a son to make "adult decisions" in his senior year of college. I’ve heard stories of love and loss, of triumph and defeat, of gratitude and grace. Each encounter is a treasure, a distillation of the repository of wisdom that these unique individuals are. The experience is at once gratifying and humbling.

So I may be tired, and I may lose a bit of myself by becoming so attached to my patients, but I can’t think of anything I would rather be doing than being a doctor.

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

Being rheumatologists, we all probably get letters on fancy lawyer letterheads asking for our office notes for a patient who is applying for disability. Then we receive more requests asking the physician to please describe in detail how much or how little work the patient can be expected to perform. Not infrequently, I even receive requests for disability assessments for patients I’ve never heard of, only to find out that I am seeing them as new patients in the coming days.

So I was excited to learn that subspecialty grand rounds was going to be given by a disability lawyer. He did a good job of explaining the law and breaking down the process.

Disability, as defined by the law, is "the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which ... has lasted or can be expected to last for a continuous period of not less than 12 months."

The process of getting disability is lengthy. According to the Social Security Administration, for the past 3 years, roughly 35% of first-time applications were granted. Of applicants who were denied, only half submitted a request for reconsideration, and of those, only 12%-14% were granted disability status.

After the agency denies an applicant twice, the applicant’s next recourse is to request a hearing. At this point an administrative law judge reviews the information, hears the case, and makes a decision. Data from the past 3 years reveals that about 60% succeed at this stage. If denied, the applicant can appeal this decision, and it goes to the same judge.

If, at the end of all that, the patient still does not get disability, he can either elevate the appeal to a federal judge or file a new application altogether.

Documentation has to be submitted to the effect that the patient cannot perform his or her past work. Then the question is whether, given his age, education, and work experience, he is able to perform other kinds of work.

The gold standard for evidence of a patient’s ability to work is a physician’s description of the patient’s functional limits. This is where those onerous forms come in. In the pesky and interminable "residual functional capacity" questionnaires, we are asked to estimate how much or how little standing/sitting/lifting the patient can do in a given amount of time.

But while the disability lawyer clarified the process of getting disability, he nonetheless interpreted the process through his own perspective. I felt that the following points he made oversimplified the important questions that physicians must answer:

• Disability is really difficult to obtain. Therefore, people who are willing to put up with the process must really be in bad shape.

This is a bogus bifurcation, a fallacy of apriorism. People will do unpleasant things, like wait a very long time to get disability, if they perceive it as the better of two unpleasant options.

• He asks his audience, "Would you hire them?"

I would counter that there may be other issues that would lead an employer to not hire someone, and the law specifically states that disability status is denied or granted "regardless of ... whether or not he would be hired if he applied for work."

• It is not easy, if you have chronic pain, to lift a 10-pound weight frequently throughout the day, which is how the Department of Labor defines "light work."

But the same paragraph that defines light work as the frequent lifting of objects weighing up to 10 pounds also says, "Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls."

I think these sorts of points illustrate a line of reasoning that does not serve patients well when they seek legal advice on applying for disability. They paint a picture that gives doctors reasons to be skeptical of the process (especially when the doctor has not even met the patient yet) and may encourage patients to seek disability when they still have the ability "to engage in any substantial gainful activity."

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected]

Being rheumatologists, we all probably get letters on fancy lawyer letterheads asking for our office notes for a patient who is applying for disability. Then we receive more requests asking the physician to please describe in detail how much or how little work the patient can be expected to perform. Not infrequently, I even receive requests for disability assessments for patients I’ve never heard of, only to find out that I am seeing them as new patients in the coming days.

So I was excited to learn that subspecialty grand rounds was going to be given by a disability lawyer. He did a good job of explaining the law and breaking down the process.

Disability, as defined by the law, is "the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which ... has lasted or can be expected to last for a continuous period of not less than 12 months."

The process of getting disability is lengthy. According to the Social Security Administration, for the past 3 years, roughly 35% of first-time applications were granted. Of applicants who were denied, only half submitted a request for reconsideration, and of those, only 12%-14% were granted disability status.

After the agency denies an applicant twice, the applicant’s next recourse is to request a hearing. At this point an administrative law judge reviews the information, hears the case, and makes a decision. Data from the past 3 years reveals that about 60% succeed at this stage. If denied, the applicant can appeal this decision, and it goes to the same judge.

If, at the end of all that, the patient still does not get disability, he can either elevate the appeal to a federal judge or file a new application altogether.

Documentation has to be submitted to the effect that the patient cannot perform his or her past work. Then the question is whether, given his age, education, and work experience, he is able to perform other kinds of work.

The gold standard for evidence of a patient’s ability to work is a physician’s description of the patient’s functional limits. This is where those onerous forms come in. In the pesky and interminable "residual functional capacity" questionnaires, we are asked to estimate how much or how little standing/sitting/lifting the patient can do in a given amount of time.

But while the disability lawyer clarified the process of getting disability, he nonetheless interpreted the process through his own perspective. I felt that the following points he made oversimplified the important questions that physicians must answer:

• Disability is really difficult to obtain. Therefore, people who are willing to put up with the process must really be in bad shape.

This is a bogus bifurcation, a fallacy of apriorism. People will do unpleasant things, like wait a very long time to get disability, if they perceive it as the better of two unpleasant options.

• He asks his audience, "Would you hire them?"

I would counter that there may be other issues that would lead an employer to not hire someone, and the law specifically states that disability status is denied or granted "regardless of ... whether or not he would be hired if he applied for work."

• It is not easy, if you have chronic pain, to lift a 10-pound weight frequently throughout the day, which is how the Department of Labor defines "light work."

But the same paragraph that defines light work as the frequent lifting of objects weighing up to 10 pounds also says, "Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls."

I think these sorts of points illustrate a line of reasoning that does not serve patients well when they seek legal advice on applying for disability. They paint a picture that gives doctors reasons to be skeptical of the process (especially when the doctor has not even met the patient yet) and may encourage patients to seek disability when they still have the ability "to engage in any substantial gainful activity."

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected]

Being rheumatologists, we all probably get letters on fancy lawyer letterheads asking for our office notes for a patient who is applying for disability. Then we receive more requests asking the physician to please describe in detail how much or how little work the patient can be expected to perform. Not infrequently, I even receive requests for disability assessments for patients I’ve never heard of, only to find out that I am seeing them as new patients in the coming days.

So I was excited to learn that subspecialty grand rounds was going to be given by a disability lawyer. He did a good job of explaining the law and breaking down the process.

Disability, as defined by the law, is "the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which ... has lasted or can be expected to last for a continuous period of not less than 12 months."

The process of getting disability is lengthy. According to the Social Security Administration, for the past 3 years, roughly 35% of first-time applications were granted. Of applicants who were denied, only half submitted a request for reconsideration, and of those, only 12%-14% were granted disability status.

After the agency denies an applicant twice, the applicant’s next recourse is to request a hearing. At this point an administrative law judge reviews the information, hears the case, and makes a decision. Data from the past 3 years reveals that about 60% succeed at this stage. If denied, the applicant can appeal this decision, and it goes to the same judge.

If, at the end of all that, the patient still does not get disability, he can either elevate the appeal to a federal judge or file a new application altogether.

Documentation has to be submitted to the effect that the patient cannot perform his or her past work. Then the question is whether, given his age, education, and work experience, he is able to perform other kinds of work.

The gold standard for evidence of a patient’s ability to work is a physician’s description of the patient’s functional limits. This is where those onerous forms come in. In the pesky and interminable "residual functional capacity" questionnaires, we are asked to estimate how much or how little standing/sitting/lifting the patient can do in a given amount of time.

But while the disability lawyer clarified the process of getting disability, he nonetheless interpreted the process through his own perspective. I felt that the following points he made oversimplified the important questions that physicians must answer:

• Disability is really difficult to obtain. Therefore, people who are willing to put up with the process must really be in bad shape.

This is a bogus bifurcation, a fallacy of apriorism. People will do unpleasant things, like wait a very long time to get disability, if they perceive it as the better of two unpleasant options.

• He asks his audience, "Would you hire them?"

I would counter that there may be other issues that would lead an employer to not hire someone, and the law specifically states that disability status is denied or granted "regardless of ... whether or not he would be hired if he applied for work."

• It is not easy, if you have chronic pain, to lift a 10-pound weight frequently throughout the day, which is how the Department of Labor defines "light work."

But the same paragraph that defines light work as the frequent lifting of objects weighing up to 10 pounds also says, "Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls."

I think these sorts of points illustrate a line of reasoning that does not serve patients well when they seek legal advice on applying for disability. They paint a picture that gives doctors reasons to be skeptical of the process (especially when the doctor has not even met the patient yet) and may encourage patients to seek disability when they still have the ability "to engage in any substantial gainful activity."

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at [email protected]