Rheum in Bloom

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

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

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

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

On online review sites, one of the measures doctors are judged by is how long patients are kept waiting in the waiting room before they are seen. But is that a fair measure?

One of my patients is habitually late, always 15-20 minutes late for her 15-minute follow-up visit. And she’s not a straightforward patient. If I am lucky, the person scheduled to come after her arrives early, so I see him or her first and my schedule is thrown off by only a few minutes. But more often I end up running late, and the rest of the patients have to wait longer than they normally would.

The last time I saw her, I politely asked her why she was late again, and after her initial protestations that she was actually on time, she said to me: "I don’t yell at you when you make me wait."

I do my best not to keep patients waiting. Of course, in a busy rheumatology practice, that is not always realistic. I need to take a history, perform a physical exam, monitor labs and x-rays and bone densities, as well as counsel on smoking cessation. Not to mention the elderly man who needs time for a good cry because he still feels guilty about having put his wife in a nursing home, or the lovely gentleman with a bad stutter who takes a very long time to finish his sentences.

Although I am typically quite prompt, sometimes I am a little late. I don’t make a habit of it, and if I am late it is with good reason. Trust me, I was not twiddling my thumbs.

But when patients are habitually late, it implies a certain expectation that they’ll be seen anyway even if they’re late. It signifies complacency toward the doctor and a lack of consideration for the other people who are inconvenienced – all the subsequent patients who are then kept waiting.

The difference between a doctor being late and a patient being late is that the doctor is providing a service, not only to that patient but to all the other patients on their schedule. If I keep you waiting, you know it’s because I was giving the patients before you the same kind of attention and level of care that you can and should expect to get. This is why patients don’t usually yell at their doctors for being late, nor do doctors deserve to be yelled at when they are.

Asking patients if they were kept waiting is not a useful question. How much or how little a doctor keeps a patient waiting is not an indication of the quality of care that the doctor is capable of giving.

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

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

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

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

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

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

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

The annual meeting of the American College of Rheumatology has just ended. As usual, it was frenetic. So many lectures to choose from, so little time (and, as I age, energy) to get to them all.

The meeting is a great opportunity for the motivated rheumatologist if you know how to use it to your advantage – and that’s a skill that’s learned over a few years of attendance. Apart from catching up with old mentors and friends, you can catch up on the latest and greatest in basic science research. You can find out how experts manage difficult cases. There are sessions on how to manage your practice more efficiently. There are thousands of posters from all over the world to peruse.

Year after year there are several sessions on the autoimmune diseases, covering everything from basic science to bench and clinical research to clinical practice. An ever-growing pool of information about the genetic and molecular bases of disease has led to a rapid expansion of treatment targets – primarily for rheumatoid arthritis but extending to other autoimmune diseases as well.

But there are certain bread-and-butter illnesses that are not as sexy and, as such, do not get as much airtime.

This year, for example, there was only one clinical session on gout, and it was held in one of the smaller rooms. Slated for the same time slot were "Dermatology Topics for Rheumatologists" and "Preclinical Autoimmunity – Potential for Prevention," both much sexier-sounding and held in much larger venues. If my small cohort of friends and colleagues is a microcosm of the attendee population, it made complete sense to do this because I was the only one out of six who was interested in gout.

I understand that "Dermatology Topics for Rheumatologists" – by far the most popular in my small cohort – is indeed interesting, but I do not think it provides terribly useful information. No offense to the ACR or to my friends who picked this topic, but while you may see an interesting rash here and there and maybe remember seeing a similar picture from a lecture that you attended somewhere, I contend that it is more valuable for a clinician to be able to treat challenging gout cases, to learn more postmarketing information about pegloticase, and to understand what asymptomatic hyperuricemia might potentially indicate.

And what of osteoarthritis? There was a popular lecture on back pain, though I heard it was not very good. OA has become one of my biggest frustrations. It is never easy to tell patients that there is not much that can be done for their condition. Thankfully there was a basic science lecture on OA. Hopefully, this means more funding for more research, and ultimately perhaps a disease-modifier as well.

I appreciate that there was a session on paraneoplastic syndromes, one on polymyalgia rheumatica, and one on osteoporosis. I see more of these conditions in my practice than I do systemic lupus erythematosus, scleroderma, or vasculitis.

Without a doubt, ours is a wonderful field to be in. Our diseases have historically been very challenging to define, let alone treat. I feel lucky to be a rheumatologist at such a heady time, when it is now possible to go into drug-free remission if you have rheumatoid arthritis. We understand mechanisms of autoimmune disease better and are making great strides in therapeutics.

But there are other diseases that have been largely ignored, for reasons that are not entirely clear to me (perhaps the unfettered profit motivation that I talked about a few columns ago?), and I think it is about time we had a more equitable distribution of resources for research. Glamorous zebras aside, I will be grateful for the day that I can tell my patients: "yes, there is a nonsurgical option for your osteoarthritis, and no, it is not an antidepressant."

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

The annual meeting of the American College of Rheumatology has just ended. As usual, it was frenetic. So many lectures to choose from, so little time (and, as I age, energy) to get to them all.

The meeting is a great opportunity for the motivated rheumatologist if you know how to use it to your advantage – and that’s a skill that’s learned over a few years of attendance. Apart from catching up with old mentors and friends, you can catch up on the latest and greatest in basic science research. You can find out how experts manage difficult cases. There are sessions on how to manage your practice more efficiently. There are thousands of posters from all over the world to peruse.

Year after year there are several sessions on the autoimmune diseases, covering everything from basic science to bench and clinical research to clinical practice. An ever-growing pool of information about the genetic and molecular bases of disease has led to a rapid expansion of treatment targets – primarily for rheumatoid arthritis but extending to other autoimmune diseases as well.

But there are certain bread-and-butter illnesses that are not as sexy and, as such, do not get as much airtime.

This year, for example, there was only one clinical session on gout, and it was held in one of the smaller rooms. Slated for the same time slot were "Dermatology Topics for Rheumatologists" and "Preclinical Autoimmunity – Potential for Prevention," both much sexier-sounding and held in much larger venues. If my small cohort of friends and colleagues is a microcosm of the attendee population, it made complete sense to do this because I was the only one out of six who was interested in gout.

I understand that "Dermatology Topics for Rheumatologists" – by far the most popular in my small cohort – is indeed interesting, but I do not think it provides terribly useful information. No offense to the ACR or to my friends who picked this topic, but while you may see an interesting rash here and there and maybe remember seeing a similar picture from a lecture that you attended somewhere, I contend that it is more valuable for a clinician to be able to treat challenging gout cases, to learn more postmarketing information about pegloticase, and to understand what asymptomatic hyperuricemia might potentially indicate.

And what of osteoarthritis? There was a popular lecture on back pain, though I heard it was not very good. OA has become one of my biggest frustrations. It is never easy to tell patients that there is not much that can be done for their condition. Thankfully there was a basic science lecture on OA. Hopefully, this means more funding for more research, and ultimately perhaps a disease-modifier as well.

I appreciate that there was a session on paraneoplastic syndromes, one on polymyalgia rheumatica, and one on osteoporosis. I see more of these conditions in my practice than I do systemic lupus erythematosus, scleroderma, or vasculitis.

Without a doubt, ours is a wonderful field to be in. Our diseases have historically been very challenging to define, let alone treat. I feel lucky to be a rheumatologist at such a heady time, when it is now possible to go into drug-free remission if you have rheumatoid arthritis. We understand mechanisms of autoimmune disease better and are making great strides in therapeutics.

But there are other diseases that have been largely ignored, for reasons that are not entirely clear to me (perhaps the unfettered profit motivation that I talked about a few columns ago?), and I think it is about time we had a more equitable distribution of resources for research. Glamorous zebras aside, I will be grateful for the day that I can tell my patients: "yes, there is a nonsurgical option for your osteoarthritis, and no, it is not an antidepressant."

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

The annual meeting of the American College of Rheumatology has just ended. As usual, it was frenetic. So many lectures to choose from, so little time (and, as I age, energy) to get to them all.

The meeting is a great opportunity for the motivated rheumatologist if you know how to use it to your advantage – and that’s a skill that’s learned over a few years of attendance. Apart from catching up with old mentors and friends, you can catch up on the latest and greatest in basic science research. You can find out how experts manage difficult cases. There are sessions on how to manage your practice more efficiently. There are thousands of posters from all over the world to peruse.

Year after year there are several sessions on the autoimmune diseases, covering everything from basic science to bench and clinical research to clinical practice. An ever-growing pool of information about the genetic and molecular bases of disease has led to a rapid expansion of treatment targets – primarily for rheumatoid arthritis but extending to other autoimmune diseases as well.

But there are certain bread-and-butter illnesses that are not as sexy and, as such, do not get as much airtime.

This year, for example, there was only one clinical session on gout, and it was held in one of the smaller rooms. Slated for the same time slot were "Dermatology Topics for Rheumatologists" and "Preclinical Autoimmunity – Potential for Prevention," both much sexier-sounding and held in much larger venues. If my small cohort of friends and colleagues is a microcosm of the attendee population, it made complete sense to do this because I was the only one out of six who was interested in gout.

I understand that "Dermatology Topics for Rheumatologists" – by far the most popular in my small cohort – is indeed interesting, but I do not think it provides terribly useful information. No offense to the ACR or to my friends who picked this topic, but while you may see an interesting rash here and there and maybe remember seeing a similar picture from a lecture that you attended somewhere, I contend that it is more valuable for a clinician to be able to treat challenging gout cases, to learn more postmarketing information about pegloticase, and to understand what asymptomatic hyperuricemia might potentially indicate.

And what of osteoarthritis? There was a popular lecture on back pain, though I heard it was not very good. OA has become one of my biggest frustrations. It is never easy to tell patients that there is not much that can be done for their condition. Thankfully there was a basic science lecture on OA. Hopefully, this means more funding for more research, and ultimately perhaps a disease-modifier as well.

I appreciate that there was a session on paraneoplastic syndromes, one on polymyalgia rheumatica, and one on osteoporosis. I see more of these conditions in my practice than I do systemic lupus erythematosus, scleroderma, or vasculitis.

Without a doubt, ours is a wonderful field to be in. Our diseases have historically been very challenging to define, let alone treat. I feel lucky to be a rheumatologist at such a heady time, when it is now possible to go into drug-free remission if you have rheumatoid arthritis. We understand mechanisms of autoimmune disease better and are making great strides in therapeutics.

But there are other diseases that have been largely ignored, for reasons that are not entirely clear to me (perhaps the unfettered profit motivation that I talked about a few columns ago?), and I think it is about time we had a more equitable distribution of resources for research. Glamorous zebras aside, I will be grateful for the day that I can tell my patients: "yes, there is a nonsurgical option for your osteoarthritis, and no, it is not an antidepressant."

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

In our office lunchroom recently a pharmaceutical rep informed us of changes to one of the more common Medicare Advantage programs that many of our patients use. During this discussion it came to light that I am not alone in my woeful lack of understanding of the different Medicare plans.

Open enrollment season for Medicare started Oct. 15 and ends on Dec. 7. This means millions of Americans older than 65 years of age need to pour through hundreds of pages of documents outlining rules on copays and deductibles, formulary coverage, and changing health care rules that have resulted from enactment of the Affordable Care Act (ACA). (The official government Medicare handbook for 2013 alone is 140 pages long.)

So, in the spirit of arming this dummy (i.e., myself) and other newbie practitioners with information to help us provide better care for our patients, here is a brief distillation of Medicare, with attention to some parts that may be more relevant to rheumatologists.

People over 65 years of age are eligible for Medicare, of which there are several parts:

• Medicare Part A. This part is also known as the Hospital Insurance Program. It covers inpatient care in hospitals and skilled nursing facilities – as long as such services meet criteria for the rendering thereof, of course.

• Medicare Part B. This is the Medical Insurance Program, which covers doctors’ services, outpatient care, and physical therapy. It covers x-rays, vaccinations, chemotherapy, and other outpatient medical treatments administered in a doctor’s office. For us this means infusional agents such as infliximab and rituximab, as well as some osteoporosis drugs such as zoledronic acid, which is infused, or denosumab, which has to be administered via subcutaneous injection by a health care professional.

• Medicare Part C. This is also called the Medicare Advantage Program. Private insurers are given money by Medicare to provide services covered under Medicare Part A and Part B. For additional premiums Advantage programs can also provide Part D coverage as well as other extras like dental coverage, vision care, and health club memberships.

It was in fact a Medicare Advantage plan, administered here in Rhode Island by a national provider, that spurred this discussion. This particular plan used to cover infusions (i.e., a Part B benefit) at 100% of the cost. However, rumor has it that beginning in 2013, the insurer will start to charge patients 20% of the cost. Imagine, then, how much money our patients on office-administered biologics will have to start shelling out for their treatments. Imagine the hardship for someone who has been well controlled, for example, on infliximab for years suddenly having to come up with several hundred dollars every other month?

• Medicare Part D. This is an outpatient prescription drug benefit. Unlike Part A and Part B, Part D is not standard. Though the different Part D prescription drug plans are regulated by Medicare, they are actually designed and administered by private insurance companies, who can dictate which drugs or drug classes they cover, and at what tier they offer the drugs. An individual can have up to 40 different Part D plans to choose from, and patients are left with the tough job of figuring out which drug plan best fits their needs.

This is also relevant to us because this is how our Medicare patients pay for most prescription drugs. This is also the source of a significant coverage gap, informally and infamously known as the "doughnut hole." In general Part D beneficiaries pay a deductible and Medicare covers the rest of the drug costs. When patients have spent about $2,900 (of their own money in the form of deductibles and of government money in the form of coverage), they become responsible for 100% of their medication costs, until they reach about $4,700 in out-of-pocket spending, at which point Medicare foots most of the bill for the rest of the year. Imagine, then, how difficult it would be for a patient with RA on a biologic, which can cost up to $3,000 a month.

Incidentally, thanks to government negotiations with pharmaceutical companies, in 2012 patients were responsible for only 50% of the cost of branded drugs instead of 100%. The ACA anticipates "closing" the doughnut hole by 2020; Medicare would continue to cover part of the drug costs, leaving consumers with a responsibility for 25% instead of 100%.

This all brings to mind wise words that a patient passed on to me. She told me that when she was first diagnosed with RA many years ago, the rheumatologist who made the diagnosis advised her to always make sure she had the best health insurance possible. I continue to share that advice with my patients today.

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

In our office lunchroom recently a pharmaceutical rep informed us of changes to one of the more common Medicare Advantage programs that many of our patients use. During this discussion it came to light that I am not alone in my woeful lack of understanding of the different Medicare plans.

Open enrollment season for Medicare started Oct. 15 and ends on Dec. 7. This means millions of Americans older than 65 years of age need to pour through hundreds of pages of documents outlining rules on copays and deductibles, formulary coverage, and changing health care rules that have resulted from enactment of the Affordable Care Act (ACA). (The official government Medicare handbook for 2013 alone is 140 pages long.)

So, in the spirit of arming this dummy (i.e., myself) and other newbie practitioners with information to help us provide better care for our patients, here is a brief distillation of Medicare, with attention to some parts that may be more relevant to rheumatologists.

People over 65 years of age are eligible for Medicare, of which there are several parts:

• Medicare Part A. This part is also known as the Hospital Insurance Program. It covers inpatient care in hospitals and skilled nursing facilities – as long as such services meet criteria for the rendering thereof, of course.

• Medicare Part B. This is the Medical Insurance Program, which covers doctors’ services, outpatient care, and physical therapy. It covers x-rays, vaccinations, chemotherapy, and other outpatient medical treatments administered in a doctor’s office. For us this means infusional agents such as infliximab and rituximab, as well as some osteoporosis drugs such as zoledronic acid, which is infused, or denosumab, which has to be administered via subcutaneous injection by a health care professional.

• Medicare Part C. This is also called the Medicare Advantage Program. Private insurers are given money by Medicare to provide services covered under Medicare Part A and Part B. For additional premiums Advantage programs can also provide Part D coverage as well as other extras like dental coverage, vision care, and health club memberships.

It was in fact a Medicare Advantage plan, administered here in Rhode Island by a national provider, that spurred this discussion. This particular plan used to cover infusions (i.e., a Part B benefit) at 100% of the cost. However, rumor has it that beginning in 2013, the insurer will start to charge patients 20% of the cost. Imagine, then, how much money our patients on office-administered biologics will have to start shelling out for their treatments. Imagine the hardship for someone who has been well controlled, for example, on infliximab for years suddenly having to come up with several hundred dollars every other month?

• Medicare Part D. This is an outpatient prescription drug benefit. Unlike Part A and Part B, Part D is not standard. Though the different Part D prescription drug plans are regulated by Medicare, they are actually designed and administered by private insurance companies, who can dictate which drugs or drug classes they cover, and at what tier they offer the drugs. An individual can have up to 40 different Part D plans to choose from, and patients are left with the tough job of figuring out which drug plan best fits their needs.

This is also relevant to us because this is how our Medicare patients pay for most prescription drugs. This is also the source of a significant coverage gap, informally and infamously known as the "doughnut hole." In general Part D beneficiaries pay a deductible and Medicare covers the rest of the drug costs. When patients have spent about $2,900 (of their own money in the form of deductibles and of government money in the form of coverage), they become responsible for 100% of their medication costs, until they reach about $4,700 in out-of-pocket spending, at which point Medicare foots most of the bill for the rest of the year. Imagine, then, how difficult it would be for a patient with RA on a biologic, which can cost up to $3,000 a month.

Incidentally, thanks to government negotiations with pharmaceutical companies, in 2012 patients were responsible for only 50% of the cost of branded drugs instead of 100%. The ACA anticipates "closing" the doughnut hole by 2020; Medicare would continue to cover part of the drug costs, leaving consumers with a responsibility for 25% instead of 100%.

This all brings to mind wise words that a patient passed on to me. She told me that when she was first diagnosed with RA many years ago, the rheumatologist who made the diagnosis advised her to always make sure she had the best health insurance possible. I continue to share that advice with my patients today.

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

In our office lunchroom recently a pharmaceutical rep informed us of changes to one of the more common Medicare Advantage programs that many of our patients use. During this discussion it came to light that I am not alone in my woeful lack of understanding of the different Medicare plans.

Open enrollment season for Medicare started Oct. 15 and ends on Dec. 7. This means millions of Americans older than 65 years of age need to pour through hundreds of pages of documents outlining rules on copays and deductibles, formulary coverage, and changing health care rules that have resulted from enactment of the Affordable Care Act (ACA). (The official government Medicare handbook for 2013 alone is 140 pages long.)

So, in the spirit of arming this dummy (i.e., myself) and other newbie practitioners with information to help us provide better care for our patients, here is a brief distillation of Medicare, with attention to some parts that may be more relevant to rheumatologists.

People over 65 years of age are eligible for Medicare, of which there are several parts:

• Medicare Part A. This part is also known as the Hospital Insurance Program. It covers inpatient care in hospitals and skilled nursing facilities – as long as such services meet criteria for the rendering thereof, of course.

• Medicare Part B. This is the Medical Insurance Program, which covers doctors’ services, outpatient care, and physical therapy. It covers x-rays, vaccinations, chemotherapy, and other outpatient medical treatments administered in a doctor’s office. For us this means infusional agents such as infliximab and rituximab, as well as some osteoporosis drugs such as zoledronic acid, which is infused, or denosumab, which has to be administered via subcutaneous injection by a health care professional.

• Medicare Part C. This is also called the Medicare Advantage Program. Private insurers are given money by Medicare to provide services covered under Medicare Part A and Part B. For additional premiums Advantage programs can also provide Part D coverage as well as other extras like dental coverage, vision care, and health club memberships.

It was in fact a Medicare Advantage plan, administered here in Rhode Island by a national provider, that spurred this discussion. This particular plan used to cover infusions (i.e., a Part B benefit) at 100% of the cost. However, rumor has it that beginning in 2013, the insurer will start to charge patients 20% of the cost. Imagine, then, how much money our patients on office-administered biologics will have to start shelling out for their treatments. Imagine the hardship for someone who has been well controlled, for example, on infliximab for years suddenly having to come up with several hundred dollars every other month?

• Medicare Part D. This is an outpatient prescription drug benefit. Unlike Part A and Part B, Part D is not standard. Though the different Part D prescription drug plans are regulated by Medicare, they are actually designed and administered by private insurance companies, who can dictate which drugs or drug classes they cover, and at what tier they offer the drugs. An individual can have up to 40 different Part D plans to choose from, and patients are left with the tough job of figuring out which drug plan best fits their needs.

This is also relevant to us because this is how our Medicare patients pay for most prescription drugs. This is also the source of a significant coverage gap, informally and infamously known as the "doughnut hole." In general Part D beneficiaries pay a deductible and Medicare covers the rest of the drug costs. When patients have spent about $2,900 (of their own money in the form of deductibles and of government money in the form of coverage), they become responsible for 100% of their medication costs, until they reach about $4,700 in out-of-pocket spending, at which point Medicare foots most of the bill for the rest of the year. Imagine, then, how difficult it would be for a patient with RA on a biologic, which can cost up to $3,000 a month.

Incidentally, thanks to government negotiations with pharmaceutical companies, in 2012 patients were responsible for only 50% of the cost of branded drugs instead of 100%. The ACA anticipates "closing" the doughnut hole by 2020; Medicare would continue to cover part of the drug costs, leaving consumers with a responsibility for 25% instead of 100%.

This all brings to mind wise words that a patient passed on to me. She told me that when she was first diagnosed with RA many years ago, the rheumatologist who made the diagnosis advised her to always make sure she had the best health insurance possible. I continue to share that advice with my patients today.

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

I had a thought experiment based on two truths about myself: I am all for universal health care, and I would not have strong objections to receiving a fixed salary.

But I know a lot of doctors who oppose Obamacare. I can see how having to see more patients and accept lower reimbursement rates, all while filling out disability paperwork for people you believe actually do have the capacity to work might leave a bad taste in any doctor’s mouth.

So here is the thought experiment: In this increasingly interdependent world, what if we could open up licensing regulations for physicians that would allow those of us who favor universal health care to practice in Canada or other parts of the United Kingdom, for example, and those who believe in traditional insurance-based health care to practice in the United States?

Wouldn’t that be ideal? Win-win.

I thought about the lung cancer patient in Wales whose surgery, radiation, and chemotherapy were all paid for by the National Health Service. Were he to develop metastatic disease, the NHS would not pay for Tarceva (erlotinib), because the National Institute for Health and Clinical Excellence (NICE) has decided that the cost of the drug is not worth the 8 extra weeks that the patient gets.

To some, this is the very definition of fairness. Health care is universal and is paid for by taxes. What is deemed reasonable is given to you completely free, and what is not, well, isn’t. It seems to be a more thoughtful, compassionate, and just way to practice medicine, and perhaps more practical as well. Everyone gets standard of care.

For others, the above scenario is inherently unfair. Why should a government agency decide what will be good for the individual? Why should government decide that an extra 8 weeks for any individual is futile and not worth taxpayer money? People should be able to buy what they can afford, regardless of outcome. It is their money after all.

And then I realized that it is in such societies where capitalism is unbridled that pharmaceuticals thrive. Capitalism provides pharmaceutical companies with the incentives to invest in research and development. And it is precisely that R&D that leads to the kind of information that NICE needs to make decisions about drug utilization.

Said another way, the information and innovation that come from cutthroat capitalist societies is precisely what allows the nationalized health care systems to succeed.

So while I may dislike the unabashed concern for profit that I imagine motivates health insurance agencies and pharmaceutical companies (who among us, left or right leaning, didn’t find the increase in colchicine pricing offensive?), I recognize their necessity and am ultimately grateful that what they do allows societies that do provide universal health care to do so.

Bonus: Interestingly enough, I found a paper from the economics department at MIT that says basically the same thing, not just about health care, but about welfare in general.

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

I had a thought experiment based on two truths about myself: I am all for universal health care, and I would not have strong objections to receiving a fixed salary.

But I know a lot of doctors who oppose Obamacare. I can see how having to see more patients and accept lower reimbursement rates, all while filling out disability paperwork for people you believe actually do have the capacity to work might leave a bad taste in any doctor’s mouth.

So here is the thought experiment: In this increasingly interdependent world, what if we could open up licensing regulations for physicians that would allow those of us who favor universal health care to practice in Canada or other parts of the United Kingdom, for example, and those who believe in traditional insurance-based health care to practice in the United States?

Wouldn’t that be ideal? Win-win.

I thought about the lung cancer patient in Wales whose surgery, radiation, and chemotherapy were all paid for by the National Health Service. Were he to develop metastatic disease, the NHS would not pay for Tarceva (erlotinib), because the National Institute for Health and Clinical Excellence (NICE) has decided that the cost of the drug is not worth the 8 extra weeks that the patient gets.

To some, this is the very definition of fairness. Health care is universal and is paid for by taxes. What is deemed reasonable is given to you completely free, and what is not, well, isn’t. It seems to be a more thoughtful, compassionate, and just way to practice medicine, and perhaps more practical as well. Everyone gets standard of care.

For others, the above scenario is inherently unfair. Why should a government agency decide what will be good for the individual? Why should government decide that an extra 8 weeks for any individual is futile and not worth taxpayer money? People should be able to buy what they can afford, regardless of outcome. It is their money after all.

And then I realized that it is in such societies where capitalism is unbridled that pharmaceuticals thrive. Capitalism provides pharmaceutical companies with the incentives to invest in research and development. And it is precisely that R&D that leads to the kind of information that NICE needs to make decisions about drug utilization.

Said another way, the information and innovation that come from cutthroat capitalist societies is precisely what allows the nationalized health care systems to succeed.

So while I may dislike the unabashed concern for profit that I imagine motivates health insurance agencies and pharmaceutical companies (who among us, left or right leaning, didn’t find the increase in colchicine pricing offensive?), I recognize their necessity and am ultimately grateful that what they do allows societies that do provide universal health care to do so.

Bonus: Interestingly enough, I found a paper from the economics department at MIT that says basically the same thing, not just about health care, but about welfare in general.

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

I had a thought experiment based on two truths about myself: I am all for universal health care, and I would not have strong objections to receiving a fixed salary.

But I know a lot of doctors who oppose Obamacare. I can see how having to see more patients and accept lower reimbursement rates, all while filling out disability paperwork for people you believe actually do have the capacity to work might leave a bad taste in any doctor’s mouth.

So here is the thought experiment: In this increasingly interdependent world, what if we could open up licensing regulations for physicians that would allow those of us who favor universal health care to practice in Canada or other parts of the United Kingdom, for example, and those who believe in traditional insurance-based health care to practice in the United States?

Wouldn’t that be ideal? Win-win.

I thought about the lung cancer patient in Wales whose surgery, radiation, and chemotherapy were all paid for by the National Health Service. Were he to develop metastatic disease, the NHS would not pay for Tarceva (erlotinib), because the National Institute for Health and Clinical Excellence (NICE) has decided that the cost of the drug is not worth the 8 extra weeks that the patient gets.

To some, this is the very definition of fairness. Health care is universal and is paid for by taxes. What is deemed reasonable is given to you completely free, and what is not, well, isn’t. It seems to be a more thoughtful, compassionate, and just way to practice medicine, and perhaps more practical as well. Everyone gets standard of care.

For others, the above scenario is inherently unfair. Why should a government agency decide what will be good for the individual? Why should government decide that an extra 8 weeks for any individual is futile and not worth taxpayer money? People should be able to buy what they can afford, regardless of outcome. It is their money after all.

And then I realized that it is in such societies where capitalism is unbridled that pharmaceuticals thrive. Capitalism provides pharmaceutical companies with the incentives to invest in research and development. And it is precisely that R&D that leads to the kind of information that NICE needs to make decisions about drug utilization.

Said another way, the information and innovation that come from cutthroat capitalist societies is precisely what allows the nationalized health care systems to succeed.

So while I may dislike the unabashed concern for profit that I imagine motivates health insurance agencies and pharmaceutical companies (who among us, left or right leaning, didn’t find the increase in colchicine pricing offensive?), I recognize their necessity and am ultimately grateful that what they do allows societies that do provide universal health care to do so.

Bonus: Interestingly enough, I found a paper from the economics department at MIT that says basically the same thing, not just about health care, but about welfare in general.

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

"The greatest enemy of knowledge is the illusion of knowledge." – Stephen Hawking

In my fellowship, I had a challenging RA case. This woman was in her 50s, and usually she was quite dynamic, personable, and spunky. But the disease was wearing her down. She developed methotrexate pneumonitis. Leflunomide gave her severe diarrhea. She got frequent upper respiratory tract infections from etanercept. We could not get her prednisone dose lower than 15 mg/day. Whenever we saw her in clinic and she had encountered a new glitch in her treatment, my preceptor would say to her "you keep me up at night." Disturbed to hear this, I wondered how insecure I would be as a newly minted rheumatologist if my preceptor, with her decades of practice, still had uncertainties.

I feel like in these, the first 3 years of practice after training, I have an inordinate number of patients who keep me up at night. They come in all shapes and sizes. Even cases that I think are straightforward frequently end up being anything but.

I like treating patients with polymyalgia rheumatica, for example, because the relief they get from a little prednisone is so dramatic and immediate. Seems straightforward, no? But I get anxious about the diagnosis sometimes – what if I’m missing a paraneoplastic syndrome? Not infrequently there are patients who absolutely refuse to go on prednisone, and I worry about them, too. Or I get anxious about tapering, because I’ve had it happen often enough that their symptoms recur at 3 mg of prednisone and I need to put them on a DMARD, none of which have any conclusive evidence of efficacy.

Rheumatoid arthritis is not always easy, either. I have had my share of refractory cases, which, in this age of different varieties of biologics, is even more frustrating. (Although, for the life of me, I cannot imagine what it must have been like to practice before the age of biologics!) It’s even worse for refractory psoriatic arthritis, for which there are fewer drug options available.

And what about scleroderma? I watched a patient’s hands progress from being simply puffy at presentation to being contracted, with severe skin tightening and skin ulcerations over the PIP joints, in just 2 years. We are lucky to be close enough to Boston that I could send the patient to a medical center there to receive an investigational therapy, which seemed to lessen the patient’s symptoms somewhat. Unfortunately, she developed urinary bladder cancer and is now ineligible to receive the experimental anti-TGF-beta in an open label extension.

But perhaps my most insomnia-inducing patient is a lovely 70-year-old man with a new diagnosis of dermatomyositis. His antinuclear antibody was negative, and he had no myositis-specific antibodies. We knew we should be looking for a malignancy, but a CT of the chest, abdomen, and pelvis was negative. A colonoscopy was next, but if that did not turn anything up, what would be next? Do we keep searching? How do we know where to look?

Worse, the pulse of methylprednisolone did not work completely, and he ended up needing a percutaneous endoscopic gastrostomy tube because he failed his swallow evaluation miserably. I was really saddened by all this. It made me feel small and insignificant in the face of such a terrible disease.

In that process of placing a PEG tube, we serendipitously found, on biopsy, adenocarcinoma at the gastroesophageal junction. Though this was, indeed, terrible news, it was a source of comfort for me that we had found the malignancy and would at least have a target for treatment.

I know he will not be my last dermatomyositis patient, and there are no prescribed guidelines for searching for a malignancy. How can we possibly find something if we have no idea what it is or where it might be?

I can think of so many more lupus, spondyloarthritis, temporal arteritis, even mechanical back pain patients who worry me, to say nothing of the not-insignificant number of patients for whom the diagnosis is uncertain. True, my learning curve has been steep in these first 3 years, but the more patients I see, the more striking the large number of phenotypes of our diseases. It’s quite humbling and has kept me up more nights than I expected.

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

"The greatest enemy of knowledge is the illusion of knowledge." – Stephen Hawking

In my fellowship, I had a challenging RA case. This woman was in her 50s, and usually she was quite dynamic, personable, and spunky. But the disease was wearing her down. She developed methotrexate pneumonitis. Leflunomide gave her severe diarrhea. She got frequent upper respiratory tract infections from etanercept. We could not get her prednisone dose lower than 15 mg/day. Whenever we saw her in clinic and she had encountered a new glitch in her treatment, my preceptor would say to her "you keep me up at night." Disturbed to hear this, I wondered how insecure I would be as a newly minted rheumatologist if my preceptor, with her decades of practice, still had uncertainties.

I feel like in these, the first 3 years of practice after training, I have an inordinate number of patients who keep me up at night. They come in all shapes and sizes. Even cases that I think are straightforward frequently end up being anything but.

I like treating patients with polymyalgia rheumatica, for example, because the relief they get from a little prednisone is so dramatic and immediate. Seems straightforward, no? But I get anxious about the diagnosis sometimes – what if I’m missing a paraneoplastic syndrome? Not infrequently there are patients who absolutely refuse to go on prednisone, and I worry about them, too. Or I get anxious about tapering, because I’ve had it happen often enough that their symptoms recur at 3 mg of prednisone and I need to put them on a DMARD, none of which have any conclusive evidence of efficacy.

Rheumatoid arthritis is not always easy, either. I have had my share of refractory cases, which, in this age of different varieties of biologics, is even more frustrating. (Although, for the life of me, I cannot imagine what it must have been like to practice before the age of biologics!) It’s even worse for refractory psoriatic arthritis, for which there are fewer drug options available.

And what about scleroderma? I watched a patient’s hands progress from being simply puffy at presentation to being contracted, with severe skin tightening and skin ulcerations over the PIP joints, in just 2 years. We are lucky to be close enough to Boston that I could send the patient to a medical center there to receive an investigational therapy, which seemed to lessen the patient’s symptoms somewhat. Unfortunately, she developed urinary bladder cancer and is now ineligible to receive the experimental anti-TGF-beta in an open label extension.

But perhaps my most insomnia-inducing patient is a lovely 70-year-old man with a new diagnosis of dermatomyositis. His antinuclear antibody was negative, and he had no myositis-specific antibodies. We knew we should be looking for a malignancy, but a CT of the chest, abdomen, and pelvis was negative. A colonoscopy was next, but if that did not turn anything up, what would be next? Do we keep searching? How do we know where to look?

Worse, the pulse of methylprednisolone did not work completely, and he ended up needing a percutaneous endoscopic gastrostomy tube because he failed his swallow evaluation miserably. I was really saddened by all this. It made me feel small and insignificant in the face of such a terrible disease.

In that process of placing a PEG tube, we serendipitously found, on biopsy, adenocarcinoma at the gastroesophageal junction. Though this was, indeed, terrible news, it was a source of comfort for me that we had found the malignancy and would at least have a target for treatment.

I know he will not be my last dermatomyositis patient, and there are no prescribed guidelines for searching for a malignancy. How can we possibly find something if we have no idea what it is or where it might be?

I can think of so many more lupus, spondyloarthritis, temporal arteritis, even mechanical back pain patients who worry me, to say nothing of the not-insignificant number of patients for whom the diagnosis is uncertain. True, my learning curve has been steep in these first 3 years, but the more patients I see, the more striking the large number of phenotypes of our diseases. It’s quite humbling and has kept me up more nights than I expected.

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

"The greatest enemy of knowledge is the illusion of knowledge." – Stephen Hawking

In my fellowship, I had a challenging RA case. This woman was in her 50s, and usually she was quite dynamic, personable, and spunky. But the disease was wearing her down. She developed methotrexate pneumonitis. Leflunomide gave her severe diarrhea. She got frequent upper respiratory tract infections from etanercept. We could not get her prednisone dose lower than 15 mg/day. Whenever we saw her in clinic and she had encountered a new glitch in her treatment, my preceptor would say to her "you keep me up at night." Disturbed to hear this, I wondered how insecure I would be as a newly minted rheumatologist if my preceptor, with her decades of practice, still had uncertainties.

I feel like in these, the first 3 years of practice after training, I have an inordinate number of patients who keep me up at night. They come in all shapes and sizes. Even cases that I think are straightforward frequently end up being anything but.

I like treating patients with polymyalgia rheumatica, for example, because the relief they get from a little prednisone is so dramatic and immediate. Seems straightforward, no? But I get anxious about the diagnosis sometimes – what if I’m missing a paraneoplastic syndrome? Not infrequently there are patients who absolutely refuse to go on prednisone, and I worry about them, too. Or I get anxious about tapering, because I’ve had it happen often enough that their symptoms recur at 3 mg of prednisone and I need to put them on a DMARD, none of which have any conclusive evidence of efficacy.

Rheumatoid arthritis is not always easy, either. I have had my share of refractory cases, which, in this age of different varieties of biologics, is even more frustrating. (Although, for the life of me, I cannot imagine what it must have been like to practice before the age of biologics!) It’s even worse for refractory psoriatic arthritis, for which there are fewer drug options available.

And what about scleroderma? I watched a patient’s hands progress from being simply puffy at presentation to being contracted, with severe skin tightening and skin ulcerations over the PIP joints, in just 2 years. We are lucky to be close enough to Boston that I could send the patient to a medical center there to receive an investigational therapy, which seemed to lessen the patient’s symptoms somewhat. Unfortunately, she developed urinary bladder cancer and is now ineligible to receive the experimental anti-TGF-beta in an open label extension.

But perhaps my most insomnia-inducing patient is a lovely 70-year-old man with a new diagnosis of dermatomyositis. His antinuclear antibody was negative, and he had no myositis-specific antibodies. We knew we should be looking for a malignancy, but a CT of the chest, abdomen, and pelvis was negative. A colonoscopy was next, but if that did not turn anything up, what would be next? Do we keep searching? How do we know where to look?

Worse, the pulse of methylprednisolone did not work completely, and he ended up needing a percutaneous endoscopic gastrostomy tube because he failed his swallow evaluation miserably. I was really saddened by all this. It made me feel small and insignificant in the face of such a terrible disease.

In that process of placing a PEG tube, we serendipitously found, on biopsy, adenocarcinoma at the gastroesophageal junction. Though this was, indeed, terrible news, it was a source of comfort for me that we had found the malignancy and would at least have a target for treatment.

I know he will not be my last dermatomyositis patient, and there are no prescribed guidelines for searching for a malignancy. How can we possibly find something if we have no idea what it is or where it might be?

I can think of so many more lupus, spondyloarthritis, temporal arteritis, even mechanical back pain patients who worry me, to say nothing of the not-insignificant number of patients for whom the diagnosis is uncertain. True, my learning curve has been steep in these first 3 years, but the more patients I see, the more striking the large number of phenotypes of our diseases. It’s quite humbling and has kept me up more nights than I expected.

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

I’ve known Mr. G. for about a year now. When he first presented to me he’d had about 6 months of hand swelling and pain, and by the time I met him he had fusiform swelling of all his PIPs. There was no doubt that he had rheumatoid arthritis.

But we had a problem, sort of. Mr. G. had a history of drug and alcohol abuse but had turned his life around. Now that he was the model of an upright citizen, he had no interest in becoming dependent on more Western medicine.

Before he saw me, he had consulted a naturopath, who recommended that he follow an anti-inflammatory diet. After my admonitions about joint damage and internal organ involvement, I ultimately agreed to let him try the diet, but only if he agreed to regular follow-up with me.

I saw him for follow-up 6 weeks later – he had followed the diet to the letter, and, contrary to my expectations, his joints were about 50% better. In broad strokes, the anti-inflammatory diet is based on the premise that the intake of fruit and vegetables as well as whole wheat is inversely associated with the risk of inflammation, for which there is support in the literature (Int. J. Vitam. Nutr. Res. 2008;78:293-8). Some variations on the diet include using organic sources as much as possible, staying away from sugar and artificial sweeteners, and avoiding tomatoes, potatoes, and eggplant.

Now of course we as doctors are not satisfied with 50% better. Our patients want to be completely pain free, and we twist ourselves into knots trying to help them achieve that. But Mr. G. was content with the state his hands were in. He felt healthy and his discomfort was manageable. He said he could live with this state of affairs.

This got me thinking about naturopathic medicine. What is it, and how does it differ from our usual advice?

In the process of answering those questions, I got to meet with Celeste Ruland, N.D., a naturopathic doctor and personal trainer. Here’s what I learned from our conversation and my own research:

Naturopathic medicine is a 4-year graduate program. Just like students of allopathic medicine, students of naturopathic medicine study anatomy, physiology, biochemistry, microbiology, pharmacology, and other basic sciences. Students of naturopathic medicine have an organ system–based curriculum. In addition, they study Chinese medicine, herbal medicine, manipulation, and homeopathy. To practice, naturopaths have to meet licensing requirements.

The philosophy, I gathered from speaking to Dr. Ruland, is to treat illness and prevent it, using the "mind/body balance."

"Where are they out of balance, and what is the best way to balance them?" she asked. "The key is to empower the patient to stay well." While prescribing remedies such as homeopathy is sometimes part of the solution, the larger part involves altering the patient’s diet, lifestyle, and environment to restore the mind/body equilibrium.

This may sound like excessive tree-huggery, but I do think there is some value to this. After all, how often do we preach lifestyle modification? It is a very mainstream concept. Recently, Dr. Dean Ornish published a piece in the New York Times about how to eat healthily. How much evidence is there that viscosupplementation works? How much evidence is there that acupuncture works? If something does not harm the patient and could be potentially helpful, I certainly have no objections. I can’t embrace the concepts of naturopathic medicine to the exclusion of Western medicine, of course, but I see a place for it in conjunction with allopathic medicine.

In addition, I kind of like the idea that there are health care providers who don’t have the same constraints that those of us who take insurance do. These providers can spend way more time counseling patients on good sleep hygiene and avoiding highly processed foods, on exercise and stress-reduction – conversations that we would love to have with our patients but don’t have time for.

Epilogue: About 8 months after his diagnosis, Mr. G developed serositis. We managed to treat it – grudgingly on his part – with steroids, but our agreement, after all, was that when the time came he would trust me with my Western medicine. He is now on a biologic DMARD and is doing very well, much better than the initial 50% improvement that had him so satisfied.

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

I’ve known Mr. G. for about a year now. When he first presented to me he’d had about 6 months of hand swelling and pain, and by the time I met him he had fusiform swelling of all his PIPs. There was no doubt that he had rheumatoid arthritis.

But we had a problem, sort of. Mr. G. had a history of drug and alcohol abuse but had turned his life around. Now that he was the model of an upright citizen, he had no interest in becoming dependent on more Western medicine.

Before he saw me, he had consulted a naturopath, who recommended that he follow an anti-inflammatory diet. After my admonitions about joint damage and internal organ involvement, I ultimately agreed to let him try the diet, but only if he agreed to regular follow-up with me.

I saw him for follow-up 6 weeks later – he had followed the diet to the letter, and, contrary to my expectations, his joints were about 50% better. In broad strokes, the anti-inflammatory diet is based on the premise that the intake of fruit and vegetables as well as whole wheat is inversely associated with the risk of inflammation, for which there is support in the literature (Int. J. Vitam. Nutr. Res. 2008;78:293-8). Some variations on the diet include using organic sources as much as possible, staying away from sugar and artificial sweeteners, and avoiding tomatoes, potatoes, and eggplant.

Now of course we as doctors are not satisfied with 50% better. Our patients want to be completely pain free, and we twist ourselves into knots trying to help them achieve that. But Mr. G. was content with the state his hands were in. He felt healthy and his discomfort was manageable. He said he could live with this state of affairs.

This got me thinking about naturopathic medicine. What is it, and how does it differ from our usual advice?

In the process of answering those questions, I got to meet with Celeste Ruland, N.D., a naturopathic doctor and personal trainer. Here’s what I learned from our conversation and my own research:

Naturopathic medicine is a 4-year graduate program. Just like students of allopathic medicine, students of naturopathic medicine study anatomy, physiology, biochemistry, microbiology, pharmacology, and other basic sciences. Students of naturopathic medicine have an organ system–based curriculum. In addition, they study Chinese medicine, herbal medicine, manipulation, and homeopathy. To practice, naturopaths have to meet licensing requirements.

The philosophy, I gathered from speaking to Dr. Ruland, is to treat illness and prevent it, using the "mind/body balance."

"Where are they out of balance, and what is the best way to balance them?" she asked. "The key is to empower the patient to stay well." While prescribing remedies such as homeopathy is sometimes part of the solution, the larger part involves altering the patient’s diet, lifestyle, and environment to restore the mind/body equilibrium.

This may sound like excessive tree-huggery, but I do think there is some value to this. After all, how often do we preach lifestyle modification? It is a very mainstream concept. Recently, Dr. Dean Ornish published a piece in the New York Times about how to eat healthily. How much evidence is there that viscosupplementation works? How much evidence is there that acupuncture works? If something does not harm the patient and could be potentially helpful, I certainly have no objections. I can’t embrace the concepts of naturopathic medicine to the exclusion of Western medicine, of course, but I see a place for it in conjunction with allopathic medicine.

In addition, I kind of like the idea that there are health care providers who don’t have the same constraints that those of us who take insurance do. These providers can spend way more time counseling patients on good sleep hygiene and avoiding highly processed foods, on exercise and stress-reduction – conversations that we would love to have with our patients but don’t have time for.

Epilogue: About 8 months after his diagnosis, Mr. G developed serositis. We managed to treat it – grudgingly on his part – with steroids, but our agreement, after all, was that when the time came he would trust me with my Western medicine. He is now on a biologic DMARD and is doing very well, much better than the initial 50% improvement that had him so satisfied.

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

I’ve known Mr. G. for about a year now. When he first presented to me he’d had about 6 months of hand swelling and pain, and by the time I met him he had fusiform swelling of all his PIPs. There was no doubt that he had rheumatoid arthritis.

But we had a problem, sort of. Mr. G. had a history of drug and alcohol abuse but had turned his life around. Now that he was the model of an upright citizen, he had no interest in becoming dependent on more Western medicine.

Before he saw me, he had consulted a naturopath, who recommended that he follow an anti-inflammatory diet. After my admonitions about joint damage and internal organ involvement, I ultimately agreed to let him try the diet, but only if he agreed to regular follow-up with me.

I saw him for follow-up 6 weeks later – he had followed the diet to the letter, and, contrary to my expectations, his joints were about 50% better. In broad strokes, the anti-inflammatory diet is based on the premise that the intake of fruit and vegetables as well as whole wheat is inversely associated with the risk of inflammation, for which there is support in the literature (Int. J. Vitam. Nutr. Res. 2008;78:293-8). Some variations on the diet include using organic sources as much as possible, staying away from sugar and artificial sweeteners, and avoiding tomatoes, potatoes, and eggplant.

Now of course we as doctors are not satisfied with 50% better. Our patients want to be completely pain free, and we twist ourselves into knots trying to help them achieve that. But Mr. G. was content with the state his hands were in. He felt healthy and his discomfort was manageable. He said he could live with this state of affairs.

This got me thinking about naturopathic medicine. What is it, and how does it differ from our usual advice?

In the process of answering those questions, I got to meet with Celeste Ruland, N.D., a naturopathic doctor and personal trainer. Here’s what I learned from our conversation and my own research:

Naturopathic medicine is a 4-year graduate program. Just like students of allopathic medicine, students of naturopathic medicine study anatomy, physiology, biochemistry, microbiology, pharmacology, and other basic sciences. Students of naturopathic medicine have an organ system–based curriculum. In addition, they study Chinese medicine, herbal medicine, manipulation, and homeopathy. To practice, naturopaths have to meet licensing requirements.

The philosophy, I gathered from speaking to Dr. Ruland, is to treat illness and prevent it, using the "mind/body balance."

"Where are they out of balance, and what is the best way to balance them?" she asked. "The key is to empower the patient to stay well." While prescribing remedies such as homeopathy is sometimes part of the solution, the larger part involves altering the patient’s diet, lifestyle, and environment to restore the mind/body equilibrium.

This may sound like excessive tree-huggery, but I do think there is some value to this. After all, how often do we preach lifestyle modification? It is a very mainstream concept. Recently, Dr. Dean Ornish published a piece in the New York Times about how to eat healthily. How much evidence is there that viscosupplementation works? How much evidence is there that acupuncture works? If something does not harm the patient and could be potentially helpful, I certainly have no objections. I can’t embrace the concepts of naturopathic medicine to the exclusion of Western medicine, of course, but I see a place for it in conjunction with allopathic medicine.

In addition, I kind of like the idea that there are health care providers who don’t have the same constraints that those of us who take insurance do. These providers can spend way more time counseling patients on good sleep hygiene and avoiding highly processed foods, on exercise and stress-reduction – conversations that we would love to have with our patients but don’t have time for.

Epilogue: About 8 months after his diagnosis, Mr. G developed serositis. We managed to treat it – grudgingly on his part – with steroids, but our agreement, after all, was that when the time came he would trust me with my Western medicine. He is now on a biologic DMARD and is doing very well, much better than the initial 50% improvement that had him so satisfied.

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

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

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

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

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

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

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

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

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

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

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

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

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

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I. 

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I. 

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I.