Speaking at HealthPartners Primary Care Update Conference

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I’m happy to be invited to speak for the upcoming conference HealthPartners Primary Care Update: Pathways to Knowledge on September 19, 2014.

I’ll be giving a presentation titled Rheumatology Pearls from 11:15-12:00, which will briefly review:

  • Common labs ordered in rheumatology
  • Differentiating inflammatory from non-inflammatory arthritis.
  • Gout: diagnosis, acute and chronic management

Download slides:

Other posts of mine that you may find helpful:

If anyone has questions before or after the conference, feel free to get in touch.

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My WordPress Setup, Plugins and Writing Tools

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“It’s best to have your tools with you. If you don’t, you’re apt to find something you didn’t expect and get discouraged.” ― Stephen King, On Writing: A Memoir of the Craft

The best way for physicians (or anyone) to control their online voice is to create their own content, and the best way for this content to be published is to have their own blog.

I am often surprised at how few physicians have what I would consider a bare minimum online presence: a simple webpage with their name and contact information. At the very least, this is necessary to take your place among the numerous physician rating websites that will show up in a search for your name.

While this may appear at first to be a more technical post, I hope that curating tips I have found helpful on running WordPress will encourage others who may be reluctant to starting their own blog.

While there are certainly more simple blogging platforms available, such as Blogger, Tumblr, or Squarespace, I specifically use WordPress given the power and flexibility of the platform, much of which comes from your choice in the additional plugins that are used.

Two ways to run WordPress

  • Free from WordPress.com. There are a number of limitations to this, such as being given a domain name (e.g. yourblog.wordpress.com) and having ads (although you can upgrade to your own domain name and to get rid of ads). The biggest downside in my opinion are the restrictions on plugins.
  • Hosting the free software available at WordPress.org on your own domain. This is the more powerful way to run WordPress, and the one I suggest. The easiest way to do this is to chose a host that supports automatic installation of WordPress (I use Dreamhost, which has been great).

This comparison chart between WordPress.com and a hosted WordPress.org site also helps explain many of the differences. If you’re worried that WordPress can get technical, keep in mind that it is the most used blogging platform, so if questions arise, finding answers is fairly easy, and the documentation is well organized.

WordPress Themes

Your WordPress theme is your template for the overall design of your page. There are a number of free options, or else you can pay for a premium theme, which is typically developed and updated by professional web designers, and will often have additional features. I use The Thesis Theme for WordPress, which has a number of simple tools for editing/managing content, and has built-in options for Google Analytics and SEO. This list of some of the most popular themes (both free and premium) can also provide some ideas.

WordPress Plugins

As mentioned above, plugins are the tools to add various function to your blog, and there are currently thousands available. The plugins that I currently use, broken into various categories are:

Security

Speeding up WordPress

  • WP Super Cache  – Generates static html files that are sent to users, which speeds up loading by reducing load on your host server (otherwise, WordPress generates a new html file each time a user accesses your site, which can be slow). I previously used W3 Total Cache, but it never seemed fast enough and has some occasional problems.
  • WP deferred javaScript – speeds up loading time of your site by deferring loading of javascript.
  • Use Google Libraries – loads any javascript libraries used on your blog from Google’s servers, which tends to be faster than loading from your own host.

SEO

  • WordPress SEO by Yoast – despite some Search engine optimization (SEO) being built into my Thesis Theme, I find that this plugin does a better job at optimizing searches for my name (which as a physician, is the result that I care most about). An alternative to consider (with overall easier setup) is All in One SEO Pack. While I haven’t compared my results with these two plugins directly, Yoast’s package seems to be more successful.
  • Google XML sitemaps – XML sitemaps are files listing your sites URLs with important information about each to search engines. Yoast’s WordPress SEO has this built in, which is likely adequate, but this plugin gives you more control.

Statistics

  • Jetpack – this is a must-have plugin that includes numerous features, but the one that I use most frequently are the site statistics.
  • Google Analytics – though not technically a plugin (Analytics is added by adding a tracking code to your site, which I do through my Thesis Theme, but could also be done through WordPress SEO), Google provides piles of free data about who is accessing your site.

Backup

Other 

  • Contact Form 7 – provides a simple but highly customizable contact form, which I like better than the one included in Jetpack.

It can also be useful to look at what plugins your favorite blogs are using with the WPThemeDetector website (although it cannot detect every plugin), or else browse the most popular plugins in the WordPress directory.

Editing Tools

While you could write blog posts directly in WordPress, it can be a bit clumsy to do so. I use MarsEdit, which connects directly to your blog and allows you to write and upload posts with multiple editing options (it even supports Markdown). By connecting to your site, it actually downloads a copy of all of your posts which acts as an additional backup. Of note, if you use Google Authenticator, you’ll have to use an application specific password, since two-factor authentication is not currently supported.

For longer or more complex writing (such as my post on Decision Fatigue), I first write everything in Markdown using Scrivener, which is an incredibly powerful writing program that local author Patrick Rhone convinced me to purchase after this tweet:

It’s like an operating system for words. Everything one would need to turn words from concept to finished product is there.

Creating content

This is the hard part. I like WordPress founder Matt Mullenweg’s post suggesting that you “write for only two people”: yourself and “a single person who you have in mind as the perfect person to read what you write”. As such, this post was inspired by Dr. Rebecca Grainger looking for tips on starting a blog via Twitter.

My suggestion for writing inspiration would be to read the book quoted at the top of this post, Steven King’s On Writing: A Memoir of the Craft.

Have suggestions regarding your own WordPress setup, especially plugins? Post them in the comments.

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The Monkeysphere: Dunbar’s Number and How Many People You Should Follow on Twitter

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“More data—such as paying attention to the eye colors of the people around when crossing the street—can make you miss the big truck.” — Nassim Nicholas Taleb, Antifragile

Twitter has had global impact in ways that never could have been imagined since the first tweets in March 2006. Now, with hundreds of millions of active Twitter users and tweets numbering over 500 million per day, we easily become tempted to follow so many accounts that it can become too noisy to be useful.

Looking for some guidance on a maximal number of accounts to follow on Twitter, I came across Dunbar’s number. This is a theory by British anthropologist Dr. Robin Dunbar that there is a “cognitive limit to the number of people we can maintain social relationships,” in which brain size “limits the number of relationships that an individual can monitor simultaneously” (PDF). He felt that this number was around 150 relationships in humans, although proposed numbers range anywhere between 100-230. The term Monkeysphere was coined in reference to an experiment confirming this correlation between brain size and social groups in monkeys.

Dunbar looked at whether his proposed cognitive limit also applies to Facebook, and wrote:

Facebook itself did a survey of its accounts about a year ago and found that the average number of friends was between 120 and 130.

The odd reality is that we are actually not capable of managing more friendships than you typically see on Facebook now—or more than people have traditionally maintained.

And concluded that:

If you have more than 150, it is because you are including people who have no meaningful relationship with you.

I don’t think there is a “correct” way to use Twitter, but given it has become my primary source of incoming information, I try to be thoughtful about both who I follow and how many I follow. Looking at an October 2012 study, the average Twitter user follows about 102 accounts, which is well within Dunbar’s observations. I certainly start to feel a bit of cognitive strain when the number I’m following is too high (which is most of the time).

My approach to Twitter is to generally focus on following thought leaders for topics I’m interested in, and have a low threshold to unfollow an account unless I’m finding they consistently add value to my network.

When you first start to filter your network and unfollow accounts on Twitter, you’ll be a bit nervous that you’ll miss something. Trust me, you won’t. If something is important, your well selected network is going to amplify that message and you’ll see it.

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Decision Fatigue in Physicians and Medicine: The Importance of Routines and Habits

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“Everything must be made as simple as possible. But not simpler.” — Albert Einstein

One of the most mentally fatiguing actions that physicians face on a daily basis is the number of decisions we must make. Although we likely only make one or two major decisions for every patient encounter, in total we make hundreds (or maybe thousands) of decisions every day. This includes deciding what labs, imaging, and other studies to order, followed by what those results mean, a diagnosis or list of possible diagnoses, treatments, monitoring, patient follow up, etc.

Unfortunately, it has been shown that the more decisions that we make over the course of a day, the worse we become at it.

The New York Times article Do You Suffer From Decision Fatigue? (highly suggested; approximately 22 minute read) begins by describing the rulings of parole board judges over the course of a year, finding that the pattern of their decisions fluctuated throughout the work day, favoring the prisoners who appeared early in the day.

The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences.

The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice.

Decision fatigue was described by Dr. Roy F. Baumeister, who demonstrated that humans have a finite store of mental energy for making decisions, which can be broken down into the Rubicon model of action phases:

  1. Predecisional Phase – assessing wishes and forming intended goal
  2. Preactional Phase / Making a Decision – planning and choosing goal-directed actions
  3. Actional Phase – implementing chosen actions
  4. Postactional Phase – evaluating whether goal was achieved

It turns out that a number of studies have shown that the act of making the decision and committing to action is more mentally demanding than any other phase.

The idea of decision fatigue is explained by Dr. Baumeister through a theory called ego depletion, where decisions are higher level executive functions thought to occur in the prefrontal cortex, and every decision we make, no matter how important or unimportant, expends some of the energy of this system, until our ability to make decisions deteriorates.

Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. In the rest of the animal kingdom, there aren’t a lot of protracted negotiations between predators and prey. To compromise is a complex human ability and therefore one of the first to decline when willpower is depleted.

This reluctancy to make trade-offs explains why the parole judges were reluctant to decide to give prisoners parole at the end of the day. As physicians, we need to be aware of the tendency for decision fatigue to occur during our long days. Unfortunately, there is no telltale symptom of when willpower to make decisions is low, and the best method to avoid decision fatigue is planning routines to avoid it:

“Good decision making is not a trait of the person, in the sense that it’s always there,” Baumeister says. “It’s a state that fluctuates.” His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower. They don’t schedule endless back-to-back meetings. They avoid temptations like all-you-can-eat buffets, and they establish habits that eliminate the mental effort of making choices. Instead of deciding every morning whether or not to force themselves to exercise, they set up regular appointments to work out with a friend. Instead of counting on willpower to remain robust all day, they conserve it so that it’s available for emergencies and important decisions.

Any opportunity to learn from extreme cases can offer incredible insight, and an extraordinary example of a decision maker to study is President Obama in Michael Lewis’ article, Obama’s Way, where he discusses routines with the President, who is well aware of the effects of decision fatigue:

You also need to remove from your life the day-to-day problems that absorb most people for meaningful parts of their day. “You’ll see I wear only gray or blue suits,” he said. “I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.” He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions. It’s why shopping is so exhausting. “You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.” [Emphasis added]

An article from EMSWorld, When Thinking is Hard: Managing Decision Fatigue, discussed the implications of decision fatigue for EMTs and paramedics and agreed that trying to reduce overall decision load was the best way to manage this problem, and noted that individuals who were able to do this had routines and habits that included thoughtful planning, which reserved willpower for when it was needed most. As healthcare professionals, they noted the importance of having these planned routines:

We tell ourselves it’s how we perform under pressure that counts most, but the sum of who we are as professionals is just as much determined by the everyday habits which make up our work.

The idea that having specific routines to improve productivity is not new. The American philosopher and physician William James (1842-1910) wrote in detail about the importance of forming regular routines and the subsequent effect of allowing our brains to remain productive in his book Habit (open domain; review on Brain Pickings).

The book, Daily Rituals: A Guided Tour of Writers’ and Artists’ Creative Habits, which describes the routines of 161 famous and inspired minds (also reviewed on Brain Pickings), is another opportunity to learn from extreme thinkers, and also quotes one of William James’ 1892 lectures from the book Habit:

The great thing, then, in all education, is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions, and live at ease upon the interest of the fund. For this we must make automatic and habitual, as early as possible, as many useful actions as we can, and guard against the growing into ways that are likely to be disadvantageous to us, as we should guard against the plague. The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work. [Emphasis added]

At this point, the effect of decision fatigue in medicine needs further research for both physicians and patients. The University of Pennsylvania currently has two studies ongoing on this topic, one looking at its role in the ICU and another looking at its role in patients’ and patient surrogates’ end-of-life choices. The Journal of Palliative Medicine has written about the problem of decision fatigue for patients who are already exhausted from severe illness, acting as a reminder to give patients and their families a chance to regroup before making important decisions.

As MDs, we will always be required to make numerous daily decisions, so we need to do what we can try reduce our own decision fatigue, which might actually improve our work as a physicians and lives in general:

  • Spend some time thinking about your routines at home and at work to avoid making additional decisions. Many of the routines described in Daily Rituals included repeating meals, dressing/grooming habits, and setups for getting work done.
  • Make important or difficult decisions first in the morning. Many of us have a habit of checking email first thing in the morning, which is often filled with a number of unimportant decisions that can wear us down. Instead, save this time of day for the tough ones.
  • When possible, put off difficult decisions that come up at the end of the day until the next morning. In the field of rheumatology, we are often faced with complex decisions, but luckily, the majority of them are not extremely time sensitive, allowing us time to research and discuss with collagues.
  • I find it difficult to say anything to the effect of “workup every case of x with tests a, b, and c”, but I do think that as physicians, we do need to have a good understanding of the workup and management for the common conditions in our fields, such that we are able to reserve decision making energy throughout the day.

Any suggestions on routines or other habits that you have found helpful? Mention them in the comments.

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Social Media and the Tweetups at #ACR13

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I was fortunate again this year to attend my sixth American College of Rheumatology Annual Meeting (ACR) in San Diego.

This year was much different than every other because of the (self-imposed) stress of organizing the #ACR13 tweetups, relating to my goal of trying to spend time meeting with people at medical conferences. I want to thank everyone who attended. Every year the tweetups have lead me to numerous ventures following the meeting, and the most notable of these have been the chance to help Crescendo Bioscience on their iOS app MyRA, as well as our ongoing project, The Rheumatology Podcast.

Every year, the use of Twitter at ACR has gotten bigger and better. It was great to meet Dr. Christopher Collins of @RheumPearls, who presented a session on The Use of Social Media in Rheumatology Education and Practice, which was a fantastic overview of the various networks that rheumatologists are using to connect.

Following #ACR13, Dr. Ronan Kavanagh wrote a great post discussing his experience with how Twitter allows one to enhance learning at medical conferences:

Live-tweeting as part of a community also allows participants to feel that they are taking part in the meeting – rather than just being passive recipients of information. It is during the informal information exchange between people that the real learning resonances and cementing of useful information takes place.

I completely agree that social media is probably the most accessible way to enhance learning at medical meetings, as users move from being a passive attendee of a lecture to an active participant. Being active in the conversation amplies the benefits of the meeting by bringing you to a higher cognitive level of learning.

The #ACR13 Tweetups went extremely well, and I’m very happy that so many people were able to make it. Since the goal of the Tweetups were to get people to connect, my request is for anyone that attended to make a point to follow up with someone you met in person. As I mentioned, each time this has led me to interesting things, and my hope is it will do the same for others.

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The first gathering was Sunday evening at an Irish-style pub called Hennessey’s Tavern, with about 20 attendees.

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Pictured below is myself with Dr. Antoni Chan, who following ACR has started a new blog called Joint Venture. His most recent post does a great job reviewing the mechanisms of HLA-B27 in ankylosing spondylitis.

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The second gathering was over lunchtime on Monday at Maryjane’s cafe at the Hard Rock Hotel, also with about 20 or so attendees, most who had not been at the first tweetup.

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Dr. Lothar Kirsch has also posted about the social aspect of #ACR13, including pictures of the tweetups

Update 12/4/2013: Dr. Philip Robinson’s post: My #ACR13 news, highlights and suggestions

Also, check out our wrap-up of #ACR13 on The Rheumatology Podcast.

Thanks again!

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