Morning Routines: Optimizing Your Startup Sequence


“It sounds plausible enough tonight, but wait until tomorrow. Wait for the common sense of the morning.” ― H.G. Wells

Humans don’t wake up ready to give 100%.

Our daily startup sequence has more similarities to older PCs that run best if restarted daily than modern devices that are always ready to go. Most of us benefit from going through some type of morning routine to get ourselves set for optimal output.

A well defined morning routine is important because it decreases the number of choices that you make in the beginning of your day, which reduces decision fatigue.

This concept was explained recently in a short podcast by Tim Ferriss:

“Imagine you have 100 points for making decisions every 24 hours. The more decisions you rack up in one area, the fewer decisions you can effectively make elsewhere.

If you make a ton of unnecessary decisions: which email to check, what to do first in the morning, what breakfast to have, you are going to deplete your hit points, and that will lead to poor decision making later, because you’re going to run out of your 100 points.”

An effective morning routine should essentially be a mental do-confirm checklist with the goal of getting minimizing or eliminating unnecessary decisions as you get ready for the day.

My typical morning has five things that rarely deviate:

  • Water. The first thing I do is drink a large glass of water. As much as I wish I could start with coffee, water is what wakes me up in the morning.
  • High protein breakfast. For at least the last 10 years, I have eaten two eggs almost every morning, typically with some sausage or ham. Rare exceptions are when I’m traveling or eat at a restaurant. (I’d love to eat bacon every day, but don’t typically have time to do the full bacon method). Sometimes I’ll have a small handful of berries, depending on the season.
  • Coffee. Usually French press with freshly ground beans. Caffeine is a wonderful thing.
  • Walk the dog. Although I typically only have time for a 5-10 minute walk on work days, I always find it refreshing to get outside and move around. Bonus: it keeps the dog from plotting against me.
  • Shower. I always feel mentally fresher after a shower, and given a chronically busy schedule, I used to say, “a shower is worth 2 hours of sleep.” We now know that sleep is much too important to skimp on, but my patients probably prefer that I take a morning shower anyway.

Over time, I’ve essentially designed my work wardrobe in the style of Steve Jobs’ daily uniform, so that I could get dressed in the dark (which occasionally happens) and still match.

On my way to work I usually listen to an audiobook on Audible (I recently finished and highly recommend Hatching Twitter) or a podcast.

What would I change about my routine?

I’m hoping to try adding about 10-15 minutes of meditation each morning right after waking, which is a common practice of many successful people. I simply need to form this into a habit.

Resources for designing your morning routine

Two websites exploring morning routines that are worth checking out are Morning Do and My Morning Routine, especially their list of recommended articles.


Rheumatology joining December 16th #NephJC discussion on “Rituximab versus Azathioprine for Maintenance in ANCA-Associated Vasculitis”


Image: Rituximab crystal structure. Credit: Wikimedia Commons.

I’m thrilled to announce that the online rheumatology community has been asked to join the next #NephJC, which will be held Tuesday, December 16 from 9-10 PM EST / 8-9 PM CST.

We’ll be discussing the recent NEJM article Rituximab versus Azathioprine for Maintenance in ANCA-Associated Vasculitis (PMID: 25372085)

For my rheumatology colleagues that are not familiar, #NephJC is a thriving nephrology journal club on Twitter and If you’re relatively new to Twitter and using hashtags, but would like to participate, the simplest way would be to follow the instructions on their site.

I’m excited to see what we’re able to learn from our nephrology colleagues, and hope us rheumatologists have much to share as well.

Background on establishment of the use of rituximab for ANCA-associated vasculitis

Until recently, the only standard therapy for treatment of ANCA-associated vasculitis had been induction with cyclophosphamide plus glucocorticoids. In 2010, the RAVE and RITUXVAS trials respectively established rituximab as non-inferior therapy for the induction of systemic and renal ANCA-associated vasculitis, with similar adverse events.

The RAVE trial compared rituximab to oral cyclophosphamide, and had a primary outcome of complete remission and tapering of glucocorticoids at 6 months, with results as follows:

  • Rituximab group: 63/99 patients (64%)
  • Cyclophosphamide group: 52/98 patients (53%)

Despite a trend toward improved outcomes in the rituximab group, the RAVE study was powered as a non-inferiority trial, and the differences between the groups were not statistically significant (p=0.09, 95% CI -3.2 to 24.3).

Upon achievement of remission in the RAVE trial, patients on cyclophosphamide were switched to azathioprine, whereas patients treated with rituximab were not given maintenance immunosuppression. Further analysis of the RAVE trial further supported effectiveness of rituximab for the induction of ANCA-associated vasculitis (discussed on episode 17 of The Rheumatology Podcast), however longer term follow up at 12 and 18 months showed the following remission rates:

  • Rituximab: 48% at 12 months, 39% at 18 months.
  • Cyclophosphamide/azathioprine: 39% at 12 months, 33% at 18 months.

Again, despite the numerical trend, this data was only able to support rituximab as non-inferior to cyclophosphamide. Additional analysis showed that in patients with relapsing disease, rituximab was superior at 6 months (p=0.01) and 12 months (p=0.009), but this effect did not extend out to 18 months (p=0.06).

The difficulty of frequent relapse in ANCA-associated vasculitis

Clearly, maintenance of remission for patients with ANCA-associated vasculitis remains a challenge and patients continue to relapse frequently despite current management strategies. Prior studies looking at remission rates with maintenance immunosuppression show significant relapse rates:


From NEJM 2008;359:2790-803.

What is the role of rituximab in maintenance therapy for ANCA-associated vasculitis?

Until now, only retrospective data has suggested that rituximab might be useful as a maintenance strategy for ANCA-associated vasculitis. This question was addressed in our current journal club article:


Study design


This study recruited patients aged 18-75 with newly diagnosed ANCA-associated vasculitis who were in complete remission after treatment with glucocorticoids plus pulsed cyclophosphamide. Disease activity was measured using BVAS, a standard vasculitis activity measure. Patients who previously received rituximab were excluded.

Treatment protocol

Induction of remission in both groups was:

  • Prednisone starting at 1 mg/kg with gradual taper, with some patients initiated with pulse methylprednisolone 500-1000 mg for 1-3 days.
  • Pulse cyclophosphamide 0.6 g/m² on days 0, 14, and 28, followed by 0.7 g/m² every 3 weeks for 3-6 additional pulses until remission was attained.

After 4-6 months, patients were randomly assigned 1:1 to either:

  • Rituximab 500 mg on days 0 and 14, then at months 6, 12, and 18.
  • Azathioprine 2 mg/kg for 12 months, 1.5 mg/kg for 6 months, then 1 mg/kg for 4 months.

In both groups, prednisone was further tapered to approximately 5 mg/day for at least 18 months, after which prednisone could be further tapered at investigator discretion.

End points

“The primary end point was the percentage of patients with major relapse (reappearance or worsening of disease with a BVAS >0 and involvement of at least one major organ, a life-threatening manifestation, or both) at month 28.”

Secondary end points: Rates of minor relapse, adverse events, mortality.


Under the hypothesis that rituximab would decrease major relapses by 25% at month 28, assuming 5% exclusion or dropout, to have 80% statistical power and a 2-sided alpha risk of 0.05, 118 patients had to be enrolled in the trial.


115 patients were enrolled (87 with GPA, 23 with MPA, and 5 with renal-limited ANCA-associated vasculitis). 58 received azathioprine and 57 received rituximab. Patient demographics were not significantly different in either group. 80% of patients had newly diagnosed disease, and 20% had relapsing disease.

Primary end point

At month 28, major relapse rates in each group were:

  • Azathioprine 17/58 patients (29%)
  • Rituximab 3/57 patients (5%)

Which was statistically significant, with hazard ratio for relapse, 6.61; 95% confidence interval, 1.56 to 27.96; P=0.002.

To put it another way, in the authors words, “hence, to avoid one major relapse, 4 patients (95% CI, 3 to 9) had to be treated with systematic rituximab infusions rather than with azathioprine.“


Secondary end points

  • Minor relapses were not statistically different between each group, with 9/58 (16%) in the azathioprine group and 6/57 in the rituximab group (11%) (p=0.43).
  • Rates of infection were similar in both groups, with 8/58 (14%) in the azathioprine group and 11/57 (19%) in the rituximab group.
  • There were two deaths in the azathioprine group, one with vasculitis involvement of the aortic valve who had a major relapse and received pulse steroids but died of E. coli bacteremia. The second patient had developed pancreatic cancer.

Author’s discussion

The authors concluded that “in the present study, rituximab was superior to azathioprine at maintaining remission of ANCA-associated vasculitis; this was especially true for granulomatosis with polyangiitis, which was the condition seen in most of the study population.”

“Our data also show that successive 500-mg infusions of rituximab, given every 6 months up to month 18 after remission, were not associated with more frequent severe adverse events than azathioprine.”

Interestingly, the authors note that the 6-month interval between rituximab infusions was chosen based on expected B-cell reconstitution and relapses after a median of 1 year.

They also state that a single 500 mg rituximab dose was chosen because patients were already in remission (i.e. B-cell deplete) and in hopes of decreasing risk of infection.

Study limitations:

  • Unblinded.
  • Unable to generalize to all patient types with ANCA-associated vasculitis since most had PR3-ANCA/GPA.
  • Leaving prednisone tapering up to discretion of investigators after 18-months (although authors note that only 2/20 relapsed patients had stopped prednisone).
  • Azathioprine maintenance until month 22, with a gradual taper (although 8 relapses occurred in the first 12 months at a dose of 2 mg/kg, and only 2 relapses occurred between months 12 and 22).

Another important point from the authors is that “several major relapses (7 of 17 in the azathioprine group and 2 of 3 in the rituximab group) occurred after treatment with the trial maintenance drugs was stopped.”

My thoughts

Having personally used rituximab in the clinical setting for both remission-induction and treatment of relapse for ANCA-associated vasculitis, and knowing that B-cells play a significant role in disease activity, I was not surprised that rituximab would be an effective therapy. This being said, I certainly did not expect a NNT of only 4 patients. I was also impressed were able to achieve these results using only single 500 mg doses of rituximab every 6 months, which may be important not only for potential decreased infectious risks, but may have financial implications as well.

One concerning observation in this study is that after stopping maintenance therapy in either group led to several major relapses. I have often wondered if we can ever safely stop all immunosuppressive therapy in these patients, and if so, how to identify which patients this can be safely achieved.

[Update 12/12/2014: Added slideshow version of the Storify below by @nephondemand. This gives additional background on management of ANCA-associated vasculitis and the trial covered in this journal club.]


Managing Difficult Decisions in Medicine with the 40-70 Rule


“Stay committed to your decisions, but stay flexible in your approach.” — Tony Robbins

The ability to make difficult decisions is the mark of an effective physician.

While decisions in medicine can be difficult for a number of reasons, ways to manage many of these challenges are readily available.

If the difficulty lies in defining the goals of treatment, we can solve this by spending more time listening and talking to our patients. If the difficulty is lack of comfort in managing a particular situation, we can become more literate with online resources to access information and converse with other physicians. If the problem is our own cognitive biases or decision fatigue, becoming aware of these errors in thinking can minimize their effect.

Despite ways to manage many of these challenges, certain decisions in medicine are inherently going to remain extremely difficult.

Features of extremely difficult decisions in medicine:

  • An incorrect decision has a high risk of adverse consequences.
  • Limited information is available to make the decision.

Of these two features, we typically have no way to control the amount of risk involved in our decision. We might also feel that we have no control over having limited information, but this is incorrect.

We are actually able to manage information limitations in medicine.

The 40-70 Rule in Decision Making

Former U.S Secretary of State and General Colin Powell is known for the 40-70 rule in decision making, stating that a leader should make a decision when they have between 40% and 70% of the information available.

”If they make the decision with less than 40% of the information, they are shooting from the hip. But waiting for more than 70% of the information delays the decision unnecessarily.”

Applying this to medical decision making:

  • By the time you have gathered 40% of necessary information, a skilled clinician should have narrowed diagnostic and treatment possibilities enough to make an effective decision.
  • By waiting for more than 70% of information to become available, we may actually increase risk by delaying a decision.

The surprising part here is that by delaying our decision beyond a certain amount of information, we may end up with worse outcomes.


#ACR14 Follow Up: Social Media Bootcamp, Tweetup, Podcasts, and #RheumJC Beginnings


Group picture from #ACR14 Tweetup.

“A tribe is a group of people connected to one another, connected to a leader, and connected to an idea. For millions of years, human beings have been part of one tribe or another. A group needs only two things to be a tribe: a shared interest and a way to communicate.” ― Seth Godin

A few weeks ago I was able to attend my seventh consecutive American College of Rheumatology Annual Meeting (ACR) in Boston.

Despite the fact I was only able to attend the meeting for a relatively short time (Saturday evening until late Monday morning), I was able to be involved in a number of activities. I’ll have to come back for sightseeing in Boston another time.

The biggest thing I was involved in while in Boston was the ACR Social Media Bootcamp, with excellent sessions on Twitter and blogging for rheumatologists.

Sunday sessions:

Monday sessions:

Also check out these Storify timelines regarding social media at #ACR14:

The next big thing was the #ACR14 Tweetup. This event is designed with the goal of helping myself and others meet more people face-to-face at a major medical conference, and was again a big success. As always, it was great to catch up with a number of friends from all over the globe.

During the conference, I had Tweeted out a link to one of my favorite articles:

In this article, titled “You don’t have to be local”, Derek Sivers writes:

You can focus your time locally or globally.

But if you over-commit yourself locally, you under-commit yourself globally, and vice-versa.

If you’re local, then you’re probably social, doing a lot of things in-person, and being a part of your community. But this means you’ll have less time to focus on creating things for the world.

If you’re global, then you want to focus on creating things that can reach out through distribution to the whole world. But this means you’ll have less time to be part of your local community.

One of the great things about having a tweetup is that by meeting some of the people that we communicate with in person, I think it brings some balance to the local vs global feeling.

Somehow during all of this, Dr. Suleman Bhana (@DrBhana) and I were able to record two live episodes of The Rheumatology Podcast.

Episode 35 – Live at #ACR14 with Dr. Philip Robinson

Episode 36 – Live at #ACR14 with Dr. Rebecca Grainger and Dr. Jonathan Hausmann

I’m also including a link to “Episode 34 – Interview with Irish rheumatologist Ronan Kavanagh”, since it was such a fun episode to record and we had discussed a bit about the social media bootcamp (among many other things).

Last, a good meeting wouldn’t come to a close without plans for the future. Toward the end of the meeting, talk about a Twitter based online journal club started to pop up, which has been deemed #RheumJC, and in the process of planning and organizing, and should launch soon.

For anyone interested in this, be sure to check out:


How to Blog – #ACR14 Social Media Bootcamp

“When you first start off trying to solve a problem, the first solutions you come up with are very complex, and most people stop there. But if you keep going, and live with the problem and peel more layers of the onion off, you can often times arrive at some very elegant and simple solutions. Most people just don’t put in the time or energy to get there.” – Steve Jobs

The goal for this presentation is to try to remove the major barriers to entry into the world of blogging. Before moving onto the technical aspects of setting up a blog, I hope that the following observations also help break down a few other hurdles that might also be holding you back from starting.

Reasons that I think people don’t blog:

Taken together, this means that:

  • As a content creator, you have the chance to have significant impact. 
  • We overestimate the effort required to become a content creator. 

Blogging has become a mainstream and powerful platform that is accessible to anyone. While detailed knowledge is not required, knowing the key terminology and background can be extremely valuable.

I would suggest spending a few minutes going through this Prezi presentation which “describes what blogs are, history, and future influence in society” and then a few minutes scanning through the terms defined in’s “Introduction to Blogging.”

There are a number of excellent blogging platforms currently available. As a general rule, the more control the platform gives you over the design of the blog, the more technical knowledge will be required. The 80/20 rule applies here again, such that only a small amount of technical understanding can have you running one of the most powerful blogging platfiorms: WordPress.

Why do I suggest WordPress?

Furthermore, I also suggest running a self-hosted WordPress site since you are not limited in ways you can change the design of your blog, nor are you limited in the plugins that you use.

Setting up your self-hosted WordPress site:

  • Chose a host to run your site. Two of the suggested hosts, bluehost and Dreamhost offer 1-click WordPress installation. I personally use Dreamhost to run this site. If you’d prefer to use a different host, the instructions are relatively simple.
  • If your hosting service doesn’t offer it, register a domain name using a company that offers WHOIS privacy. My suggestion for this service is Hover.
  • Going through the tutorial on will teach you almost everything else you need to know.

Designing your site:
The best way to set up the design of your site is a relatively personal one. I think you should design a blog that you would enjoy reading. As you browse around the web, take note of which sites draw you in. Personally, my blog is inspired by the readability and simplicity of and Instapaper.

In WordPress, the design or template of your blog is called a Theme. currently has over 2,700 free and premium themes in their directory, which can be installed with just a few clicks. Alternatively, a number of more advanced profession themes are available. This site is currently running Thesis 2 (of note, this specific theme does require you to be a bit more technically savvy, but the majority of them minimal additional technical knowledge).

WordPress Plugins:

These are the tools to add various functions to your blog.  Often enough, whenever you think of something you want to add, a plugin already exists that you can install and have running with a few clicks. Details of the types and specific plugins I recommend are covered in my prior post: My WordPress Setup, Plugins and Writing Tools.

Driving traffic to your site:
Typically, the biggest driver of readers to your site is going to come from social media. On Twitter. adding a hashtag can be extremely helpful, and in the world of rheumatology, top suggestions  would be to use a conference hashtag such as #ACR14 or the rheumatology education hashtag #RheumEdu.

The other way that people will find their way to your blog will be through search engines, which is referred to as organic search. Because of the algorithms that Google uses to index pages, it is worthwhile to think a little bit about Search Engine Optimization (SEO) so that readers can find you organically. On WordPress, there are a number of plugins that take care of most of this automatically. If you’re looking to really dig into some of the details you can read through Google’s Starter Guide.

The 80/20 of SEO for most bloggers simply requires that you:

  • Write good content.
  • Give your writing accurate titles.

Adding visual content to your site:

Humans are visual creatures, so adding images to your site and posts both draws people in, and will also improve social sharing.
If you’re not using one of your own photos, options for free images include public domain images (works that are free of known copyright around the world) or else images with certain Creative Commons licenses that usually allow works to be used with proper attribution. A nice resource for free images can be found here.

Last, I want to include a list of all of the current active rheumatology bloggers that I’m aware of at the time of #ACR14:

(This post was originally fueled by significant amounts of caffeine, so if I’ve accidentally left you off this list, please let me know.)


Thanks for checking out my presentation. As always, if feel free to give feedback or ask questions below in the comments, or else by reaching out to me on Twitter at @psufka.

1 comment