Rheum in Bloom

When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.

Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)

I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)

Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.

This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.

After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."

Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.

Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.

When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.

Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)

I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)

Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.

This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.

After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."

Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.

Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.

When Solicitor General Donald Verrilli Jr. stood before the U.S. Supreme Court in March to argue for the constitutionality of the Affordable Care Act, Supreme Court watchers all commented about how poor a job he did. Most of the attacks on him seemed legitimate. Though, to be fair, he was trying to stave off attacks from a largely antagonistic court making specious arguments about broccoli. There was even a sound byte of him choking. (Is nothing beneath the Internet these days?) The general sense was one of defeat.

Naturally then, it came as a surprise when the Supreme Court upheld the ACA, with no less than the George W. Bush appointee Chief Justice John Roberts providing the swing vote and offering up as justification an interpretation of the mandate as being a tax, something that even the administration was hesitant to do. ("Tax" is a bad word for both sides of the political divide these days.)

I was seeing patients that day, but between 9:50 and 10:16 a.m., I snuck out every chance I could to check websites that were live blogging the event. I held my breath and bit my nails, just like, I assume, you did. (For the record, said websites are the New York Times, Slate.com, and NPR. Thankfully I did not turn to CNN or Fox News. I would have had a heart attack, and then I might have missed the happy ending.)

Bracing myself for what I thought was a done deal, I was thrilled, exhilarated, relieved, and overjoyed by the outcome. I excitedly knocked on my boss’s exam room door (he was in with a patient) to deliver the news. Indeed I did my best Mexican jumping bean impression.

This is a wonderful coup for an administration plagued by a Congress determined to see it fail. Better still, this is a coup for Americans. Emma Lazarus wrote in her poem, "The New Colossus": "Give me your tired, your poor/Your huddled masses yearning to breathe free/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!" These are words referring to the first immigrant populations on Ellis Island, immortalized on a plaque on your Lady Liberty.

After all, to whom much is given, much is required in return. The writer and journalist Michael Lewis (of "Moneyball" fame), in his commencement address at this year’s Princeton University graduation, said it best when he spoke of humility: "Recognize that if you have had success, you have also had luck, and with luck comes obligation. You owe a debt, and not just to your gods. You owe a debt to the unlucky."

Francois Guisot, a French statesman from the late 1700s, said: "Not to be a republican at twenty is proof of want of heart; to be one at thirty is proof of want of head." (This quote often is misattributed, by the way, to Winston Churchill.) But kindness should be a virtue regardless of your age.

Dr. Chan is in practice in Pawtucket, R.I. E-mail her at rhnews.com.

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

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

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

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

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

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

The mind is a powerful thing. In arguing for a better understanding of the unconscious, Carl Jung said "Man’s task is ... to become conscious of the contents that push upward from the unconscious. ... The sole purpose of human existence is to kindle a light in the darkness of mere being."

I recently had a new-patient visit with a woman in her 40s who had been diagnosed initially with Lyme disease (serologically negative) in the 1990s, then chronic fatigue syndrome, then irritable bowel syndrome, and then fibromyalgia. "Oh, and I forgot to mention, I have migraines, too." She had been to multiple specialists over many years and, while I am sure many treatment options had been offered to her, her perception was that no one had been able to help her.

After taking an inventory of her complaints, I asked if she had been abused as a child.

In a defiant and defensive tone she said "Yes, but that has nothing to do with why I am here." She came across as very matter-of-fact; she recognized her history of abuse, had already been through years of therapy about it, and felt that it was no longer an issue. So why was I bringing it up?

In situations in which I think the main diagnosis is fibromyalgia or chronic fatigue syndrome, I make it a point to ask if there has been trauma or abuse in the patient’s history. More often than not, the answer is yes. Of course, patients do not think this has anything to do with what they’re seeing me for, but childhood or adolescent trauma can rear its ugly head in ways other than explicitly identified mental health pathologies. I suspect there is an overlap between psychiatric illness (depression, anxiety, posttraumatic stress disorder, bipolar disorder) and those vague somatic complaints of the NOS ("not otherwise specified") variety. The universe of "secondary gains" seems so nebulous, especially for us doctors who picked a profession rooted in as much empiricism as possible. But we’ve all seen the Cymbalta ads that say "depression hurts." Perhaps we’ve even experienced this ourselves.

My sister is a mental health therapist in Washington, D.C. She recently recounted her experience with a "client" (as mental health therapists call their patients) who came to her because the client’s primary care physician suggested it as part of a treatment regimen for fibromyalgia. The client was unsure why she was in my sister’s office, but she gave it a chance anyway. After a few months the client began to see how her somatic complaints might have been a response to years of trauma that she’d experienced, and indeed, she started to experience a lessening of her pain.

Meanwhile, by the end of her first visit, my new patient seemed more receptive to the possibility that her complaints might stem from her past; it started to make sense. "I’ve seen seven doctors for this problem, and you’re the only one that’s asked me about my childhood."

A biblical scholar once said that there is a difference between "to cure" and "to heal." "To cure," according to him, was what doctors, nurses, and medical technicians do: They take your x-ray, they examine your blood under the microscope. "To heal," on the other hand, refers to meaning, to well-being, to integration. To peace.

Maybe there should not be a distinction.

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

The mind is a powerful thing. In arguing for a better understanding of the unconscious, Carl Jung said "Man’s task is ... to become conscious of the contents that push upward from the unconscious. ... The sole purpose of human existence is to kindle a light in the darkness of mere being."

I recently had a new-patient visit with a woman in her 40s who had been diagnosed initially with Lyme disease (serologically negative) in the 1990s, then chronic fatigue syndrome, then irritable bowel syndrome, and then fibromyalgia. "Oh, and I forgot to mention, I have migraines, too." She had been to multiple specialists over many years and, while I am sure many treatment options had been offered to her, her perception was that no one had been able to help her.

After taking an inventory of her complaints, I asked if she had been abused as a child.

In a defiant and defensive tone she said "Yes, but that has nothing to do with why I am here." She came across as very matter-of-fact; she recognized her history of abuse, had already been through years of therapy about it, and felt that it was no longer an issue. So why was I bringing it up?

In situations in which I think the main diagnosis is fibromyalgia or chronic fatigue syndrome, I make it a point to ask if there has been trauma or abuse in the patient’s history. More often than not, the answer is yes. Of course, patients do not think this has anything to do with what they’re seeing me for, but childhood or adolescent trauma can rear its ugly head in ways other than explicitly identified mental health pathologies. I suspect there is an overlap between psychiatric illness (depression, anxiety, posttraumatic stress disorder, bipolar disorder) and those vague somatic complaints of the NOS ("not otherwise specified") variety. The universe of "secondary gains" seems so nebulous, especially for us doctors who picked a profession rooted in as much empiricism as possible. But we’ve all seen the Cymbalta ads that say "depression hurts." Perhaps we’ve even experienced this ourselves.

My sister is a mental health therapist in Washington, D.C. She recently recounted her experience with a "client" (as mental health therapists call their patients) who came to her because the client’s primary care physician suggested it as part of a treatment regimen for fibromyalgia. The client was unsure why she was in my sister’s office, but she gave it a chance anyway. After a few months the client began to see how her somatic complaints might have been a response to years of trauma that she’d experienced, and indeed, she started to experience a lessening of her pain.

Meanwhile, by the end of her first visit, my new patient seemed more receptive to the possibility that her complaints might stem from her past; it started to make sense. "I’ve seen seven doctors for this problem, and you’re the only one that’s asked me about my childhood."

A biblical scholar once said that there is a difference between "to cure" and "to heal." "To cure," according to him, was what doctors, nurses, and medical technicians do: They take your x-ray, they examine your blood under the microscope. "To heal," on the other hand, refers to meaning, to well-being, to integration. To peace.

Maybe there should not be a distinction.

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

The mind is a powerful thing. In arguing for a better understanding of the unconscious, Carl Jung said "Man’s task is ... to become conscious of the contents that push upward from the unconscious. ... The sole purpose of human existence is to kindle a light in the darkness of mere being."

I recently had a new-patient visit with a woman in her 40s who had been diagnosed initially with Lyme disease (serologically negative) in the 1990s, then chronic fatigue syndrome, then irritable bowel syndrome, and then fibromyalgia. "Oh, and I forgot to mention, I have migraines, too." She had been to multiple specialists over many years and, while I am sure many treatment options had been offered to her, her perception was that no one had been able to help her.

After taking an inventory of her complaints, I asked if she had been abused as a child.

In a defiant and defensive tone she said "Yes, but that has nothing to do with why I am here." She came across as very matter-of-fact; she recognized her history of abuse, had already been through years of therapy about it, and felt that it was no longer an issue. So why was I bringing it up?

In situations in which I think the main diagnosis is fibromyalgia or chronic fatigue syndrome, I make it a point to ask if there has been trauma or abuse in the patient’s history. More often than not, the answer is yes. Of course, patients do not think this has anything to do with what they’re seeing me for, but childhood or adolescent trauma can rear its ugly head in ways other than explicitly identified mental health pathologies. I suspect there is an overlap between psychiatric illness (depression, anxiety, posttraumatic stress disorder, bipolar disorder) and those vague somatic complaints of the NOS ("not otherwise specified") variety. The universe of "secondary gains" seems so nebulous, especially for us doctors who picked a profession rooted in as much empiricism as possible. But we’ve all seen the Cymbalta ads that say "depression hurts." Perhaps we’ve even experienced this ourselves.

My sister is a mental health therapist in Washington, D.C. She recently recounted her experience with a "client" (as mental health therapists call their patients) who came to her because the client’s primary care physician suggested it as part of a treatment regimen for fibromyalgia. The client was unsure why she was in my sister’s office, but she gave it a chance anyway. After a few months the client began to see how her somatic complaints might have been a response to years of trauma that she’d experienced, and indeed, she started to experience a lessening of her pain.

Meanwhile, by the end of her first visit, my new patient seemed more receptive to the possibility that her complaints might stem from her past; it started to make sense. "I’ve seen seven doctors for this problem, and you’re the only one that’s asked me about my childhood."

A biblical scholar once said that there is a difference between "to cure" and "to heal." "To cure," according to him, was what doctors, nurses, and medical technicians do: They take your x-ray, they examine your blood under the microscope. "To heal," on the other hand, refers to meaning, to well-being, to integration. To peace.

Maybe there should not be a distinction.

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

I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.

Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.

But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.

Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."

With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.

I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.

When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.

I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.

Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.

She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.

At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.

I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.

Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.

I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?

Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].

I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.

Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.

But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.

Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."

With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.

I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.

When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.

I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.

Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.

She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.

At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.

I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.

Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.

I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?

Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].

I am a huge fan of adjunctive, nonpharmacologic treatment for a lot of patients. As physicians, our instinct is to provide instant relief, and we do that typically by prescribing medications for every problem that patients bring to our attention. But I frequently remind patients that they need to do some of the work themselves. I am a huge proponent of physical therapy, weight loss and exercise, mental health therapy, and, lately, acupuncture.

Coincidentally, the American College of Rheumatology has just come out with new guidelines for the management of osteoarthritis, and acupuncture is on the list of nonpharmacologic interventions conditionally recommended for knee osteoarthritis.

But acupuncture treatments are not inexpensive. Insurance companies rarely cover these, and a session can easily set you back $100. So when a patient told me about Community Acupuncture, I got excited about the possibilities.

Community Acupuncture is a nationwide movement started by acupuncturists from Portland, Ore., and touted as the "calmest revolution ever staged." I think the best description of their vision comes from their website, www. pocacoop.com: "[I]t is not just those who practice, or are licensed to practice, or educated to practice acupuncture who get to define what acupuncture is and isn’t. With Community Acupuncture, the definition cannot only come from those delivering care, but those who are served by acupuncture must have also have a role in defining it. To define acupuncture as a technique, or part of a body of knowledge, leaves out its active role in those who are most affected by it: our patients."

With the goal of making acupuncture more affordable and accessible to a larger number of patients, the treatments are quite literally delivered in a community setting, with multiple patients in a treatment room. This allows for a larger volume of patients, which allows the treatment center to charge less. The website explains that it follows a social business model. "That means: The goal is not to accumulate a lot of money in the business, or for anyone to be able to take money out of the business in the form of profit. The goal is to do as much good as we can do, as long as we can break even and remain sustainable. If there happen to be profits, they will be reinvested into the business," according to the website.

I was intrigued by this idea. I had already started sending patients to my local Community Acupuncture center, but I wanted to have firsthand experience. So I made myself an appointment.

When I walked in, what struck me was how laid back the energy was. It did not feel at all like a stuffy doctor’s office. I suppose that’s the idea. The receptionist knew everyone who walked in the door by name. A sign on her desk tells of the "sliding scale" of payment – pay anywhere from $15 to $35, and pay only what you can. No questions, no need to present your tax return.

I walked into the treatment rooms. There were three of them, and each room had anywhere from four to eight recliners. It was later in the day so there were a lot of empty recliners. I situated myself in one and tried to get comfortable. I admit I picked a room that was empty, so I cannot speak to the experience of having other patients in the room. But I suspect part of the attraction for some people is that they’re in the treatment room with others, that they are not alone. There must be a feeling of solidarity or community.

Chris, my acupuncturist, then came to start the treatment. She understood that I was here for the experience, so there were no questions about my health (and truthfully I would have been hard-pressed to find something to complain about anyway). She felt my pulses – she called this "listening" to my pulses – I suppose to gauge the current state of my health.

She then proceeded to put the needles in me. The needles are tiny, so tiny she didn’t draw blood, so tiny they’re much smaller than the teriparatide or etanercept or tuberculin syringe needles. They’re probably a 40-gauge. With a quick light tap she put each one in place, three in each hand, three in each foot, and one on my forehead. This process was painless, though I did feel the needle that went into my glabella. The feeling is akin to getting an intramuscular injection, though on a much smaller scale. The pain did not last long though.

At Community Acupuncture, they let you sit in the treatment room for as long as you need to; you decide when your treatment is done. I suspect it must feel empowering for the patients to feel like they have some degree of control over the treatments, to be able to say when they feel they’re ready. Chris came and removed the needles after about 30 minutes.

I wish I could say I felt a difference after my treatment, but in truth I had not come in to be treated for anything. I just wanted the experience, and I got just that. My acupuncturist gave me a great overview of what acupuncture is, and what Community Acupuncture in particular can offer.

Some conditions lend themselves well to treatment with acupuncture. While acupuncture makes no claims about correcting a structural problem (it will not reverse your knee osteoarthritis), it might help with functional problems. Things like pain, irritable bowel syndrome symptoms, even allergy symptoms.

I am aware of studies that show that there is no difference between sham acupuncture and real acupuncture. But what of it? A placebo effect, after all, is still a therapeutic effect. This makes me think that there must be more to acupuncture than just the application of needles in the right places. Maybe it is the environment of the acupuncturist’s office. Maybe it is the aura of mystery that Eastern medicine inherently possesses, or the fact of being physically touched by the provider. These are intangibles that I think can make a difference. As Chris put it, "we’re all here to treat people, make them better somehow." That’s a nice ideal for physicians to strive for, don’t you think?

Dr. Chan is a rheumatologist in private practice in Pawtucket, R.I. Readers can write to her at [email protected].

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.

When I was a little girl of about 8 years, I complained a lot to my mom about ankle pain. Every night, she would put some salve on my ankles and massage them, and this always made me feel better. Naturally, she was concerned and took me to see my pediatrician.

I remember the questions the pediatrician asked me: Did my joints get swollen? Were they warm? Was it difficult to walk? Was I worse in the mornings? To all of those questions my answer was no, yet the pediatrician pronounced that I had juvenile rheumatoid arthritis. I was then placed on a fixed-dose combination of Maalox and aspirin.

I took home some brochures from the pediatrician’s office and borrowed some library books. From reading (with as much understanding as an 8-year-old possibly can have), I instinctively knew the diagnosis was inaccurate; after all, I had answered NO to all of her questions. But still, I was worried. How could I not be? Everything I read about the disease told me I would be crippled by the time I reached age 30.

When, after a few months, the medication hadn’t helped, and I did not develop any of her ominous suggestions (swelling, warmth, loss of function), I confirmed my suspicion that the pediatrician had simply made it up.

I suspect the pediatrician did what she thought was best, but it was a reckless decision. If she had been just a little bit more careful, if she had paid attention to my "no" answers instead of hearing what she wanted to, she would have figured out that I just wanted my mother’s attention – a textbook case of a secondary gain.

I would like to think that I am much more thoughtful in listening to my patients. I try to be as reasonably certain as possible before I give patients a diagnosis of a chronic potentially debilitating illness. Primum non nocere, after all. Sometimes, the kindest thing we can do is to not do anything at all.

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

When I was a little girl of about 8 years, I complained a lot to my mom about ankle pain. Every night, she would put some salve on my ankles and massage them, and this always made me feel better. Naturally, she was concerned and took me to see my pediatrician.

I remember the questions the pediatrician asked me: Did my joints get swollen? Were they warm? Was it difficult to walk? Was I worse in the mornings? To all of those questions my answer was no, yet the pediatrician pronounced that I had juvenile rheumatoid arthritis. I was then placed on a fixed-dose combination of Maalox and aspirin.

I took home some brochures from the pediatrician’s office and borrowed some library books. From reading (with as much understanding as an 8-year-old possibly can have), I instinctively knew the diagnosis was inaccurate; after all, I had answered NO to all of her questions. But still, I was worried. How could I not be? Everything I read about the disease told me I would be crippled by the time I reached age 30.

When, after a few months, the medication hadn’t helped, and I did not develop any of her ominous suggestions (swelling, warmth, loss of function), I confirmed my suspicion that the pediatrician had simply made it up.

I suspect the pediatrician did what she thought was best, but it was a reckless decision. If she had been just a little bit more careful, if she had paid attention to my "no" answers instead of hearing what she wanted to, she would have figured out that I just wanted my mother’s attention – a textbook case of a secondary gain.

I would like to think that I am much more thoughtful in listening to my patients. I try to be as reasonably certain as possible before I give patients a diagnosis of a chronic potentially debilitating illness. Primum non nocere, after all. Sometimes, the kindest thing we can do is to not do anything at all.

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

When I was a little girl of about 8 years, I complained a lot to my mom about ankle pain. Every night, she would put some salve on my ankles and massage them, and this always made me feel better. Naturally, she was concerned and took me to see my pediatrician.

I remember the questions the pediatrician asked me: Did my joints get swollen? Were they warm? Was it difficult to walk? Was I worse in the mornings? To all of those questions my answer was no, yet the pediatrician pronounced that I had juvenile rheumatoid arthritis. I was then placed on a fixed-dose combination of Maalox and aspirin.

I took home some brochures from the pediatrician’s office and borrowed some library books. From reading (with as much understanding as an 8-year-old possibly can have), I instinctively knew the diagnosis was inaccurate; after all, I had answered NO to all of her questions. But still, I was worried. How could I not be? Everything I read about the disease told me I would be crippled by the time I reached age 30.

When, after a few months, the medication hadn’t helped, and I did not develop any of her ominous suggestions (swelling, warmth, loss of function), I confirmed my suspicion that the pediatrician had simply made it up.

I suspect the pediatrician did what she thought was best, but it was a reckless decision. If she had been just a little bit more careful, if she had paid attention to my "no" answers instead of hearing what she wanted to, she would have figured out that I just wanted my mother’s attention – a textbook case of a secondary gain.

I would like to think that I am much more thoughtful in listening to my patients. I try to be as reasonably certain as possible before I give patients a diagnosis of a chronic potentially debilitating illness. Primum non nocere, after all. Sometimes, the kindest thing we can do is to not do anything at all.

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

I was recently in Manila to attend a family function. While there we had quite an interesting experience that began when my brother-in-law, a previously healthy 41-year-old white male of Croatian descent, came to breakfast one morning limping. As we sat in the hotel restaurant chatting over coffee and fresh mangoes, the rheumatologist in me could not resist asking to see his foot. He promptly complied, offering up his be-flip-flopped foot for me to examine.

Wikimedia Commons/Public Domain/Creative Commons License

As my sister put it, his foot looked exactly like all the pictures of gout one finds from doing a cursory Google search. I can only imagine she meant James Gillray’s 1799 caricature of podagra. Please permit me to indulge in an aside on the significance of the mythological reference: Podagra was the spawn of Bacchus’ seduction of Venus. Fittingly, in the 18th century gout was believed to be a consequence of too much alcohol and sex.

Being the responsible, newly minted rheumatologist that I am, I wanted to crystal-prove the diagnosis. Also, my brother-in-law still had a long vacation in front of him including another 8 days in Manila and 3 in Tokyo. We all wanted him to feel better so that he could enjoy his trip. But how to do so? More to the point, how to do so in Manila, where I am an ocean and a continent away from my office, my materials, and my microscope?

Supremely confident, I thought I would proceed anyway; tap the first metatarsophalangeal joint, maybe give him a steroid injection. I asked my sister to get materials: lidocaine, Kenalog, a few 3-cc syringes, a few 22- and 25-gauge needles, Betadine, sterile gloves, etc. I was prepared to give my old Philippine medical license number, but there was no need. Prescriptions are superfluous in my homeland. Interestingly, I found this to be true on a recent trip to Spain as well.

But my brother-in-law got in the way of my grand and grandiose plans. As he put it, there was no way he was going to let me MacGyver his toe. While I am no stranger to office and bedside procedures, this was completely unknown to him. There was no scenario in which he was going to let me near his inflamed and tender toe in the nonsterile environment of his hotel room!

In the end we settled on getting him some oral Prednisone, again, without need of a prescription. My initial dose of 40 mg have no effect, but when I put him on 80 mg, it worked like a charm. He was able to enjoy a few more beers, sweet succulent shellfish, and the splendor and strangeness of Tokyo.

I was recently in Manila to attend a family function. While there we had quite an interesting experience that began when my brother-in-law, a previously healthy 41-year-old white male of Croatian descent, came to breakfast one morning limping. As we sat in the hotel restaurant chatting over coffee and fresh mangoes, the rheumatologist in me could not resist asking to see his foot. He promptly complied, offering up his be-flip-flopped foot for me to examine.

Wikimedia Commons/Public Domain/Creative Commons License

As my sister put it, his foot looked exactly like all the pictures of gout one finds from doing a cursory Google search. I can only imagine she meant James Gillray’s 1799 caricature of podagra. Please permit me to indulge in an aside on the significance of the mythological reference: Podagra was the spawn of Bacchus’ seduction of Venus. Fittingly, in the 18th century gout was believed to be a consequence of too much alcohol and sex.

Being the responsible, newly minted rheumatologist that I am, I wanted to crystal-prove the diagnosis. Also, my brother-in-law still had a long vacation in front of him including another 8 days in Manila and 3 in Tokyo. We all wanted him to feel better so that he could enjoy his trip. But how to do so? More to the point, how to do so in Manila, where I am an ocean and a continent away from my office, my materials, and my microscope?

Supremely confident, I thought I would proceed anyway; tap the first metatarsophalangeal joint, maybe give him a steroid injection. I asked my sister to get materials: lidocaine, Kenalog, a few 3-cc syringes, a few 22- and 25-gauge needles, Betadine, sterile gloves, etc. I was prepared to give my old Philippine medical license number, but there was no need. Prescriptions are superfluous in my homeland. Interestingly, I found this to be true on a recent trip to Spain as well.

But my brother-in-law got in the way of my grand and grandiose plans. As he put it, there was no way he was going to let me MacGyver his toe. While I am no stranger to office and bedside procedures, this was completely unknown to him. There was no scenario in which he was going to let me near his inflamed and tender toe in the nonsterile environment of his hotel room!

In the end we settled on getting him some oral Prednisone, again, without need of a prescription. My initial dose of 40 mg have no effect, but when I put him on 80 mg, it worked like a charm. He was able to enjoy a few more beers, sweet succulent shellfish, and the splendor and strangeness of Tokyo.

I was recently in Manila to attend a family function. While there we had quite an interesting experience that began when my brother-in-law, a previously healthy 41-year-old white male of Croatian descent, came to breakfast one morning limping. As we sat in the hotel restaurant chatting over coffee and fresh mangoes, the rheumatologist in me could not resist asking to see his foot. He promptly complied, offering up his be-flip-flopped foot for me to examine.

Wikimedia Commons/Public Domain/Creative Commons License

As my sister put it, his foot looked exactly like all the pictures of gout one finds from doing a cursory Google search. I can only imagine she meant James Gillray’s 1799 caricature of podagra. Please permit me to indulge in an aside on the significance of the mythological reference: Podagra was the spawn of Bacchus’ seduction of Venus. Fittingly, in the 18th century gout was believed to be a consequence of too much alcohol and sex.

Being the responsible, newly minted rheumatologist that I am, I wanted to crystal-prove the diagnosis. Also, my brother-in-law still had a long vacation in front of him including another 8 days in Manila and 3 in Tokyo. We all wanted him to feel better so that he could enjoy his trip. But how to do so? More to the point, how to do so in Manila, where I am an ocean and a continent away from my office, my materials, and my microscope?

Supremely confident, I thought I would proceed anyway; tap the first metatarsophalangeal joint, maybe give him a steroid injection. I asked my sister to get materials: lidocaine, Kenalog, a few 3-cc syringes, a few 22- and 25-gauge needles, Betadine, sterile gloves, etc. I was prepared to give my old Philippine medical license number, but there was no need. Prescriptions are superfluous in my homeland. Interestingly, I found this to be true on a recent trip to Spain as well.

But my brother-in-law got in the way of my grand and grandiose plans. As he put it, there was no way he was going to let me MacGyver his toe. While I am no stranger to office and bedside procedures, this was completely unknown to him. There was no scenario in which he was going to let me near his inflamed and tender toe in the nonsterile environment of his hotel room!

In the end we settled on getting him some oral Prednisone, again, without need of a prescription. My initial dose of 40 mg have no effect, but when I put him on 80 mg, it worked like a charm. He was able to enjoy a few more beers, sweet succulent shellfish, and the splendor and strangeness of Tokyo.

By the time I started my residency training in 2004, the ACGME regulations that limit residency training to 80 hours/week were in place. I had finished medical school and a rotating internship in the Philippines and so was not a stranger to taking call every other day or every 3 days. Being on call, taking care of one admission after another, can be mind numbing. Compared to the grueling experience of the system in the Philippines, it was refreshing to be on call only once every 4 nights. I thought I would use the free time to read up on things that I encountered.

But even for the most well-intentioned resident such as me, that was not the case. Like other residents, I ended up using the extra hours for non-medical pursuits. Residents are frequently so exhausted from all the in-hospital work that by the time the day ends the last thing they want to do is study some more. Realistically, the most learning that I got from residency did not happen on my off days, it happened in all those hours that I spent in the hospital – from both patient care work and educational activities.

I contend that despite the standardization of medical education and training, what each doctor knows is quite distinct. Medical school teaches us the science; training teaches us the art. We are each a product of a unique permutation of experiences – cases we saw, mistakes we made, pearls we gleaned from our mentors.

People who advocate for fewer resident work hours cite studies that show that better-rested house officers make fewer mistakes, or that performance on standardized exams is no different for residents with different work hours. But the art of medicine is so much more than avoiding mistakes or performing well on standardized exams.

I learned the basics of rheumatology from my fellowship, seeing patients 12 hours a week, and spending the rest of the time on didactic work. But in my first 2 years of practice of seeing patients 5 full days a week, my skill as a rheumatologist has improved exponentially.

I understand the importance of ensuring patient and house staff safety. But this is a multifactorial problem and I wonder if we are barking up the wrong tree here, and compromising physician quality as a result.

By the time I started my residency training in 2004, the ACGME regulations that limit residency training to 80 hours/week were in place. I had finished medical school and a rotating internship in the Philippines and so was not a stranger to taking call every other day or every 3 days. Being on call, taking care of one admission after another, can be mind numbing. Compared to the grueling experience of the system in the Philippines, it was refreshing to be on call only once every 4 nights. I thought I would use the free time to read up on things that I encountered.

But even for the most well-intentioned resident such as me, that was not the case. Like other residents, I ended up using the extra hours for non-medical pursuits. Residents are frequently so exhausted from all the in-hospital work that by the time the day ends the last thing they want to do is study some more. Realistically, the most learning that I got from residency did not happen on my off days, it happened in all those hours that I spent in the hospital – from both patient care work and educational activities.

I contend that despite the standardization of medical education and training, what each doctor knows is quite distinct. Medical school teaches us the science; training teaches us the art. We are each a product of a unique permutation of experiences – cases we saw, mistakes we made, pearls we gleaned from our mentors.

People who advocate for fewer resident work hours cite studies that show that better-rested house officers make fewer mistakes, or that performance on standardized exams is no different for residents with different work hours. But the art of medicine is so much more than avoiding mistakes or performing well on standardized exams.

I learned the basics of rheumatology from my fellowship, seeing patients 12 hours a week, and spending the rest of the time on didactic work. But in my first 2 years of practice of seeing patients 5 full days a week, my skill as a rheumatologist has improved exponentially.

I understand the importance of ensuring patient and house staff safety. But this is a multifactorial problem and I wonder if we are barking up the wrong tree here, and compromising physician quality as a result.

By the time I started my residency training in 2004, the ACGME regulations that limit residency training to 80 hours/week were in place. I had finished medical school and a rotating internship in the Philippines and so was not a stranger to taking call every other day or every 3 days. Being on call, taking care of one admission after another, can be mind numbing. Compared to the grueling experience of the system in the Philippines, it was refreshing to be on call only once every 4 nights. I thought I would use the free time to read up on things that I encountered.

But even for the most well-intentioned resident such as me, that was not the case. Like other residents, I ended up using the extra hours for non-medical pursuits. Residents are frequently so exhausted from all the in-hospital work that by the time the day ends the last thing they want to do is study some more. Realistically, the most learning that I got from residency did not happen on my off days, it happened in all those hours that I spent in the hospital – from both patient care work and educational activities.

I contend that despite the standardization of medical education and training, what each doctor knows is quite distinct. Medical school teaches us the science; training teaches us the art. We are each a product of a unique permutation of experiences – cases we saw, mistakes we made, pearls we gleaned from our mentors.

People who advocate for fewer resident work hours cite studies that show that better-rested house officers make fewer mistakes, or that performance on standardized exams is no different for residents with different work hours. But the art of medicine is so much more than avoiding mistakes or performing well on standardized exams.

I learned the basics of rheumatology from my fellowship, seeing patients 12 hours a week, and spending the rest of the time on didactic work. But in my first 2 years of practice of seeing patients 5 full days a week, my skill as a rheumatologist has improved exponentially.

I understand the importance of ensuring patient and house staff safety. But this is a multifactorial problem and I wonder if we are barking up the wrong tree here, and compromising physician quality as a result.