Welcome ‘The Rheumatologist’ Readers

Paul Sufka


“How can you squander even one more day not taking advantage of the greatest shifts of our generation? How dare you settle for less when the world has made it so easy for you to be remarkable?” – Seth Godin

Welcome to anyone who is here after reading the article “A Rheumatologist’s Tips for Tweeting and Blogging” in the June 2013 issue of The Rheumatologist. Thanks for checking out my blog!

A few of my favorite posts to introduce you to my blog:

My main other project online is The Rheumatology Podcast, where I am one of three other co-hosts of a biweekly audio discussion regarding rheumatology and technology topics. Episodes are also available on iTunes. I would greatly appreciate it if you would check it out!

Twitter has been a great way for me to connect with many other rheumatologists and other physicians all over the world, many of whom I have been able to meet at national ACR meetings. I wrote a three part series of blog posts regarding rheumatologists from around the world that I have interacted with online.

Twitter is also greatly useful in ongoing medical education. At the time of writing this post, I have been actively following a number of rheumatologist tweeting updates from EULAR 2013 in Madrid (June 12-15, 2013).

If for no other reason, physicians should become involved in social media because there are two realities regarding your online reputation, as Dr. Bryan Vartabedian points out,:

1. You have no control over what people say

2. You have 100% control of the story you createHow to control reputation online

I strongly advocate for starting your own website or blog, even if used for nothing more than having your name on the internet with your clinic contact information. A simple way to create your own website was posted on our podcast website and was discussed on episode 6 of our podcast.

I would be happy to connect with anyone. Feel free to write a comment below, drop me a note through my contact page, or else contact me at @psufka on Twitter.

Flat Design and EMRs

Paul Sufka


“Indifference towards people and the reality in which they live is actually the one and only cardinal sin in design.” – Dieter Rams

A current trend in software user interface is called flat design, which tries to:

  • Embrace the fact that we are working in a two-dimensional (“flat”) digital workspace (as opposed to a physical item, such as a paper chart)
  • Clean up visual appearance by embracing the whitespace and removing unnecessary borders and edging.
  • Focus keeping the interface minimalistic and efficient.

An example of efficient design that comes to mind is described in Steve Jobs’ biography, where he had recognized (and demanded) the need to limit any user action to as few steps as possible while designing the original iPod with the click wheel.

Flat design is the next evolution of Dieter Rams ten principles of good design.

Compare this to skeuomorphism, defined in this interactive infographic, as “a design element of a product that imitates design elements that were functionally necessary in the original product design, but which have become ornamental in the new design.”

Skeuomorphic design is highly prevalent in EMR systems, which try to mimic paper medical records. The problem with this is assumption that most physicians are used to using paper charts, and that imitating these old design elements electronically is going to improve user experience. As in the Dieter Rams quote above, indifference to the reality that EMRs need to be updated to the modern electronic world is a cardinal sin in their design.

In fact, efforts to make EMRs mimic paper charts may be making usability and understanding worse, increasing training time to as much as 12 hours. Many have an array of redundant, outdated, or unclearly labeled tabs that were previously useful in a paper chart. Most of them still lack any type of advanced search, which is a critical function when trying to make any use of big data. The format by which many lab results and other patient data is often thoughtlessly displayed as just electronic copy of what would previously be printed out, as opposed to a format that is designed to improve understanding and actionability. The simple act of ordering a patient prescription is made much more difficult by trying to copy features of the paper prescription pad, as opposed to giving the clinician ways to make this process more efficient and less error prone. Some examples of poor user interface design in EMRs are beyond explanation.

While I don’t necessarily expect an EMR to be easy to use, we do need efforts made to simplify workflow in the world of modern patient care.

Update (5/28/13): Also check out Designmodo’s Principles of Flat Design

Update (7/2/13): Article from The Economist: What is skeuomorphism?

Lifelong Learning and Teaching in Medicine

Paul Sufka

2013 01 19 14 13 30

 “It gave a tremendous level of self-confidence, that through exploration and learning one could understand seemingly very complex things in one’s environment.” – Steve Jobs

In medicine, we knowingly commit ourselves to lifelong learning. Very early in our medical education, most of us are told that some portion of what we are taught will be found to be incorrect (or at least will be updated), which requires each of to find ways to keep up with our respective fields. Despite the amount of learning that we do, many of us have little understanding of the actual learning process.

A commonly used phrase in medicine is “see one, do one, teach one”, making reference to increasing levels of understanding of the subject matter.

A more formal model to classify levels of learning objectives is Bloom’s Taxonomy (Wikipedia), which is divided into three types of learning, or domains: cognitive (knowledge), affective (emotional), and psychomotor (physical skills). For the purposes of medical education and this post, our focus is on the cognitive domain.

The cognitive domain is further divided into six increasing levels of learning, which are recognized by goals and objectives that the learner is able to demonstrate at each level. These have been updated since the original publication (the Wikipedia article above shows the old version).

Below is my attempt to give a simple explanation of the current iteration of the cognitive domain of Bloom’s modified taxonomy (listed from lowest to highest level of learning):

  1. Knowledge: Lowest level actions such as memorizing, recall of information, and basic concepts. Example: Listing types of inflammatory arthritis. 
  2. Comprehension: Understanding of information and meanings as well as context. Example: Understanding that arthritis could be divided into non-inflammatory and inflammatory causes, and further subdividing inflammatory causes into categories such as monoarticular, oligoarticular, and polyarticular.
  3. Application: Problem solving and making use of the information. Example: Recognition of a patient with inflammatory polyarthritis and deciding to order RF and CCP as part of the workup.
  4. Analysis: Organization of parts and recognition of patterns. Example: Recognition that a patient with inflammatory polyarthritis has additional features such as rash and nail pitting, suggesting psoriatic arthritis.
  5. Synthesis: Being able to formulate, defend, and argue information. Example: Developing a treatment plan for a patient that has an unclear diagnosis because of overlapping features.
  6. Creation: Being able to assemble, recommend, criticize, support, or discriminate information. Example: Selecting a treatment plan for a patient who has failed standard therapies or has comorbid conditions making treatment decisions difficult.

The differences between levels of learning can be subtle, but by looking at the action verbs used to describe each level from the references above, you should be able to roughly estimate your current level of understanding for a topic.

As an example, most adult rheumatologists should find themselves at the level of creation in terms of management of rheumatoid arthritis, but might only be at the level of knowledge or comprehension for a topic such as the autoinflammatory syndromes (e.g. Familial Mediterranean fever or TRAPS).

Recognizing your current level of understanding is helpful when you want to increase your level of understanding for a topic. For the autoinflammatory syndromes, one might recognize that they are only aware of the names of these syndromes (knowledge level), and increase their learning level by organizing features that differentiate these syndromes into a chart (comprehension level or higher).

As mentioned above with “see one, do one, teach one”, an effective way to maximize the learning process is to teach. While some of us are actively teaching residents and fellows to keep us functioning at the higher levels of learning, many do not have this option.

My suggestion would be to set up a simple website or blog (which we discuss in episode 6 of the podcast) to share what you have learned with others. The mental processes involved in organizing information to be shared will further advance your understanding, which can be furthered by ongoing discussions on social media. In my case, being part of discussions on The Rheumatology Podcast and posting on the blog there have undoubtedly increased my learning level for a number of topics.

If you’re not ready to make the jump to blogging quite yet, Twitter is an excellent option for sharing short bullet points (for an example of this done extremely well, check out @RheumPearls).

The Worldwide Community of Rheumatologists (Part 3: European Edition)

Paul Sufka


“You are the average of the five people you spend the most time with.” – Jim Rohn

This is a continuation of a series of series of posts where I have been profiling some of the most active rheumatologists in social media. Be sure to check out part 1 and part 2.

I’ll keep the intro short since this is a longer post that profiles five rheumatologists in Europe: Spain, Ireland, Netherlands, United Kingdom, and Germany.

Also, I put together a Twitter list of the rheumatologists in this series, to make things easier to follow.


Name: Dr. Jose Campos
Twitter: @JoseCamposMD

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I obtained my MD at Complutense University of Madrid (Spain) in 1998, and before I started my Rheumatology residency at Clinica Puerta de Hierro (Madrid) (2005-2009), I completed a Clinical Immunology residency at Ramon y Cajal Hospital (Madrid) from 2000 to 2004. On 2008 Puerta de Hierro Hospital moved to Majadahonda, a neighbouring city about 20km from Madrid, and since 2009 when I finished my Residency I work as Staff Physician at the Rheumatology Dept, with a temporary contract signed each 3 to 9 months, and as Associate Researcher for the Spanish Network on Inflammation & Rheumatic Disorders.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I live in Central Madrid (Chamartin neighbourhood), which is better known for harbouring Santiago Bernabeu Soccer Stadium, home of Real Madrid team, which is a must visit for soccer fans (not for me, as I support Atletico de Madrid). Madrid has plenty of word famous tourist attractions, and if I had to choose just three, I would recommend a visit to the “Arts Triangle” (Prado Museum, Thyssen-Bornemisza Museum, Queen Sofia Museum) near Paseo de la Castellana (Castilian´s mall), a visit to Royal Palace and Our Lady of Almudena Cathedral near Plaza de Oriente (best sights of our little Manzanares river, with a huge recently renovated state-of-the-art park surrounding it) and a Sunday morning walk from Gran Via (Main St) to the Rastro (flea market) ending with an informal “tapas” meal. (Hope to see you in EULAR congress this year!)

3. What languages do you speak?

I speak Spanish as my mother tongue and I am fluent in English (but feel I am not as good as a I was when I lived in the US, from 4 to 6 years old!)

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

Working for the Spanish National Health System under state-tax-funded Social Security, which brings full coverage and access to all Spanish residents, has been a great privilege over the years. For example, access to biologic therapies has been self audited by each Department on the basis of the Spanish Society for Rheumatology guidelines, and so has been access to MRI and other medical technologies (despite variable waiting lists). However, things began to change in the last couple of years due to economic crisis, and practicing is becoming harder as new fees for medications, restrictions on biologic therapies and even exclusion from health cover for some groups are being implemented.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

My (scarce) time outside work is for my family (I am a proud father of three, two girls-8 &4y.o.- and a boy that was born just a month ago) and for practising and enjoying sports. I have been an associated amateur 7-a side-soccer player for the last 20 years (it become to an end this season…) but the sport I have liked most is rugby, which I played on my Med School years. From now on, it is time for paddle tennis and jogging…I spare golf for the next decade.

6. What types of social media do you use most frequently? Which are the most useful?

I am active on Facebook for personal use and on twitter for professional matters. Both are very useful… but time-consuming!

7. Has social media affected how you practice rheumatology? If so, how?

Undoubtedly, but quite indirectly yet. What I value most is getting direct access to locomotor system specialists (not only Rheumatologists) from all over the world, and the never ending chat that is always on. (And of course plenty of people and matters outside medicine…)

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

Not yet… It is one of my New Year resolutions…


Name: Dr. Ronan Kavanagh
Twitter: @RonanTKavanagh
Blog: www.ronankavanagh.ie

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I am an Irish (Galway) medical graduate and did my most of my postgraduate training and research in Cambridge in the UK. I have been an accredited rheumatologist since 1998.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I work in full time private practice in a 2 man rheumatology partnership in Galway which is based in the West of Ireland. To experience Galway city at its best, visit in July to soak up the atmosphere at the Macnas parade (as part of the Galway Arts Festival) sipping a pint of Guinness outside Neachtain’s bar before strolling down to Ard Bia restaurant for dinner. Don’t miss Conemara.

3. What languages do you speak?

I speak English, some French and a little Irish (Gaelic). How do you say “hello” in Gaelic?: ‘Dia dhuit’ is the Gaelic for Hello (translated as ‘God be with you)’

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

I’m very fortunate to be working in the private sector where I feel we can provide a high quality, patient focused service to our patients. Because all Irish citizens are entitled to government financial support for their medications, modern treatments are affordable to most patients.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

I have wide interests outside medicine. My first love would be music. I played keyboards (badly) in a number of bands over the years and I still play for my own enjoyment. I love music, cinema and live comedy. Exercise is a good way of burning off the day for me so I run, cycle and swim a lot. I read most days, like cooking and photography.

6. What types of social media do you use most frequently? Which are the most useful?

Twitter, Facebook, Video (Clear.MD), RSS feeds, Google circles, LinkedIn and the Rheumatology podcast. Twitter is by far the most useful.

7. Has social media affected how you practice rheumatology? If so, how?

The network of people that social media has given me access to and the information that they share have transformed the way I think and practice medicine. It has opened my eyes to, and helped me make surprising connections between, all sorts of seemingly unrelated disciplines and healthcare. It’s all about the collective power of communities to gather, filter and make relevant information for me. I also love the idea of learning medicine while at the same time learning about other stuff. It seems like less of a chore to me now.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

I have a blog which I update as often as I can – usually once every two weeks or so. I write about anything that comes into my mind but everything from stuff about the practice of medicine, my frustration with big medical conferences, new technologies and social media.

9. Anything else you would like to say that I wouldn’t know to ask about?

To be truly effective rheumatologists we need to look after ourselves too, forgive ourselves for being imperfect and give ourselves a pat on the back from time to time.


Name: Dr. Michiel Zandbelt
Twitter: @zandbelt
Blog: zandbelt.wordpress.com

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I studied Psychology for one year before I started my study Medicine.
After finishing 6 years of Medicine study I continued doing research at the department of Rheumatology for my PhD, and about 4 years later I started my further 6 year specialization to become a Rheumatologist.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I am living in the Netherlands. actually I have never thought of the second question you are asking here. I guess what’s worth visiting in the Netherlands depends very much on the visitor’ s interest cultural stuff in the Capital City of Amsterdam, our expertise on ” water management” constructions and architecture stuff fighting sea levels as a partly below sea level situated small country and finally especially when a colleague decides to come to visit me I would of course show him the region where I live and the hospital where I am working.

3. What languages do you speak?

Dutch, English, German and a bit of French.

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

In the Netherlands there is an active research community in the field of rheumatology and I dare to say that amongst countries like e.g. Sweden and United Kingdom and France, the Netherlands despite being a small country have a prominent role in the european field of rheumatology. Much effort is also been put in clinimetrics. Although several great databases are emerging it has not yet reached the outstanding level of data gathering taking place in Sweden. Like other countries controlling the rapidly rising costs of health care is a major (political) issue in the Netherlands and thus rheumatologists like elsewhere in the world feel pressure from the government and insurance companies to reduce prescribing expensive biologicals. At the same time of course cutting edge standards of care are wanted, a difficult dilemma. In the Netherlands rheumatologists try to play a sort of pro-active role instead of waiting which measures the government will just decide to role out over them. There is a national study ongoing in which is analysed what happens to patients with stable disease activity on anti-TNF therapy when that therapy is stopped or given in less short interval / frequency. But in general compared to other countries we as rheumatologists have to realize in the Netherlands that our situation is relatively luxury compared to other countries.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

Building and maintaining websites, communicating and learning via social media (professional and personal contacts), photography, running, play chess (online via chess.com), following the (world) news (including some politics every now and then), supporting my favourite dutch soccer club, and last but not least of course my family (wife and children) and helping with their hobbies as well.

6. What types of social media do you use most frequently? Which are the most useful?

Twitter, Facebook, Google+ and LinkedIn.

7. Has social media affected how you practice rheumatology? If so, how?

So far it hasn’t yet as far as contact with patients concerns, however in an indirect way, by communicating with my colleagues from all over the world, knowledge is shared and can actually be part of my decision-making in daily clinical practice. As such, it indirectly influences my way of practicing rheumatology. I did a 2-year pilot with Twitter and patients being able to ask non-urgent questions via Direct Messages. Only a handful of patients used that opportunity in 2 years time. I feel one does not necessarily need one specific type of social media (just tools) but regardless the tool you choose having an asynchronous way of communicating with patients or colleagues in your hospital is definitely of crucial importance. Questions can be posted and messages can be answered at a time that suits the asking or answering person. One does not have to wait to get connected by phone and the doctor is not interrupted whilst busy with other daily practice work. In essence email or SMS could also serve that objective.

Personally my interests and plans with blogging and social media now move towards education. Social media and weblogs can be a very powerful way of patient education as well as trainees education. A major part of educational material available for patients is still the classic leaflet or handout whether printed or put on a website. There are however numerous people that either cannot read at all or that are just more visual oriented, so I expect a lot more YouTube movies (one way) and also electronic learning via e.g. Google+ Hangouts or other ways of web conferencing (interactive) like e.g. Moodle connected with BigBlueButton. The clear.md startup that Ronan bravely uses as pioneer is one example of hitting the bull’ s eye on the topic I just raised.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

Yes I have a blog. It is fueled very irregularly, but quality matters more for me then quantity and “having to”. My current blog is in english and rather oriented towards colleagues and other healthcare professionals. It serves as my personal notepad to remember things from scientific meetings or visits to other colleagues by writing a summary out. I share these via my blog, but having written a blog posting the contents are stored in my own brain as well, just like preparing for an exam and writing some abstracts from the books you have read. I do not have a blog aimed at my patients yet (that would be one in Dutch of course), but far more than all of the mentioned social media maintaining a blog really puts you on the map and enables profiling yourself and attracting people towards your site via Google Search results or via social media directing to your blog. Howard Luks, the orthopedic surgeon with his excellent continuously evolving website is of great inspiration for me when I would start a patient oriented weblog.



Name: Dr. Philip Gardiner
Twitter: @PhilipGardiner
Blog: www.philipgardiner.me.uk

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I didn’t have a career before going into medicine, but I was brought up in India and as a lad I sometimes helped my dad count pills in the village hospital where he worked. I trained in Queen’s University Belfast, did my postgraduate training in N. Ireland and my postgraduate research in Newcastle Upon Tyne, England. One of my rheumatology mentors as a ‘resident’ or junior doctor in Belfast was Stanley Roberts, a great character and an inspiration to a generation of trainees.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I live in Londonderry/Derry, which is currently the UK ‘City of Culture’ – so that would be a great place to visit this year! From here you can take a trip into the ‘wilds’ of Donegal, or follow in the footsteps of the mythical giant Finn McCool at the Giant’s Causeway in Antrim. Or you could visit the new Titanic museum in Ulster’s second city, Belfast!

3. What languages do you speak?

English. Sadly, I’m not multi-lingual!

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

We’re at the ‘western outpost’ of the UK, and our hospital covers a wide rural area from Coleraine in the North down to Femanagh in the South. We are further from our medical school than any other hospital in NI, and to tackle the logistics we pioneered the use of videoconferencing to help teach our rheumatology students. Doing research far away from university labs has its own challenges, and this has prodded me towards unlikely collaborations with non-medical scientists and broadened my horizons. At the moment I am involved in a project testing the use of datagloves in measuring joint movement in people with arthritis.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

I enjoy photography, kayaking and hill walking.

6. What types of social media do you use most frequently? Which are the most useful?

I use Twitter to link up with other rheumatologists and keep my CME right up to date. I also use LinkedIn and Google+ from time to time.

7. Has social media affected how you practice rheumatology? If so, how?

I have enjoyed the ability to interact with other rheumatologists and share our excitement and/or skepticism about new ideas/research.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

I did set up one of the first arthritis websites in the mid 1990s (arthritislink.org.uk) – to give patients some basic information about their medication and their condition. It was very much an amateur effort, but people did use it and I kept it going until there were other more up to date and comprehensive web sites available. I also set up the first website for the Irish Society for Rheumatology (www.isr.ie) – which I believe has the distinction of being the shortest domain name of any rheumatology society! Thankfully, the website now has a professional design and oversight! I now write occasional blogs on medical topics when the notion takes me (www.philipgardiner.me.uk). Twitter is useful for letting people know that you have written something new and getting a bit of feedback.

LMK Wochenblatt 003

Name: Dr. Lothar M. Kirsch
Twitter: @Rheumatologe
Blog: rheumatologe.blogspot.com

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I started studying Chinese, Social Anthropology and Japanology before studying medicine. I’ve spent 1 ½ years in Taiwan and also did some of my medical internship there. I studied in my home town, Cologne; first I have been involved in Oncology and infectious diseases like HIV. My doctoral thesis treated coping and depression in patients receiving a cardiac pacemaker. Then I changed to Rheumatology.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I live in the Rhine valley and I’d like someone from abroad visit the Cologne Cathedral and the Roman-Germanic Museum next to the cathedral. A short trip to the hilly country (Bergisches Land) East of Cologne would make the day perfect.

3. What languages do you speak?

German, English, Mandarin, French, a little Spanish, Dutch, I’ve learned Latin at grammar school, a smattering of Japanese, rudiments of Italian and Russian, and of course Kölsch.

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

I practice in the country, in a small town, which is nice and green. Disadvantage is going to work. After work it is easy to relax at the Rhine or in the fields. Patients might have difficulties getting here because of the limited public transport.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

Travel and languages, writing haiku.

6. What types of social media do you use most frequently? Which are the most useful?

I use Twitter and Google+ regularly, sometimes Facebook, but I’m not too fond of Facebook.

7. Has social media affected how you practice rheumatology? If so, how?

Starting twitter made me also start a blog. I use it for information as to put a presentation on the blog after I’ve done the talk. Or I refer to information on my blog to patients, so I know at least what they (also) read and it saves time explaining.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

I write about Rheumatology in German and English. I publish poems, mostly Haiku in English. And I write about my travels. Recently I’ve started writing on subjects, where patients might be ripped off.

9. Anything else you would like to say that I wouldn’t know to ask about?

Some people think they can reach people with job offers or trying to sell something on twitter. Twitter isn’t a good platform for these purposes. But it’s a great virtual place to meet people with equal interests. Information is spread much quicker than with other media.


I may add more rheumatologists to this series in the future. If anyone has suggestions (including yourself), please let me know. Thanks!

The Worldwide Community of Rheumatologists (Part 2: Southern Hemisphere Edition)

Paul Sufka

2012-07-17 19.30.21

“The Internet is becoming the town square for the global village of tomorrow.” – Bill Gates

In my last post I started talking about reasons for building your community in social media. For newcomers to social media, the idea of connecting with people on the other side of the world can be both intimidating and exciting.

On his blog, Derek Sivers (entrepreneur/programmer and must-read blogger) said this about balancing your local and global community:

You can focus your time locally or globally.

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

Derek concludes that:

 Both are necessary. Neither is right or wrong, but you need to be aware that you can choose the local/global balance that feels best to you, no matter the norms.

Although I agree with this, I also feel that for most people, the balance is probably shifted locally. The fact we can even consider the possibility of over-committing globally is something that probably has only been possible in the last generation or so with high-speed travel and widespread communications. I think most people would benefit from expanding their network globally.

Over this series of posts, I hope to profile a number of the most active rheumatologists in the world of social media, with hopes that we can continue to expand our global community. In this post I start with three rheumatologists from the Southern hemisphere: two from Australia and one from Colombia.


Name: Dr. Irwin Lim
Twitter: @_connectedcare
Website: bjcconnectedcare.com

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine? 

I received my medical education at the University of Sydney. I was going to opt for cardiology but while working as a junior internal medicine registrar in rheumatology, I decided that I really enjoyed the diversity of conditions & the long-term patient relationships one has in rheumatology. I also liked the work-life balance most rheumatologists seemed to enjoy.

I am now in my 10 year as a specialist rheumatologist.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I live in Sydney, Australia.

Two things I would suggest an overseas visitor do:
a) Walk across the Sydney Harbour Bridge from the North Shore to Circular Quay, where they can then enjoy the Sydney Opera House & have a lovely meal with gorgeous views of our beautiful harbour
b) Visit one of our iconic beaches, such as Bondi Beach. Go along a walk on the foreshore.

3. What languages do you speak?

Only English

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

I am lucky to live in a cosmopolitan city in a rich, modern country. While all health systems have their problems, on the whole, patients here are lucky and receive a very high standard of care in both public and private sectors.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

I have 3 children under 9, and that invariably means a busy, fulfilling family life.

My other work role is as a director of a multidisciplinary, group rheumatology practice. The number of people in our organisation, BJC Health, now numbers over 30.

I am lucky that my work is also my main interest. My conviction is that best care for arthritis & rheumatic conditions requires an integrated approach and so much of what I do involves working towards the goal of creating an environment for us to deliver positive outcomes for patients through this Connected Care.

6. What types of social media do you use most frequently? Which are the most useful?

I mostly use my blog and twitter. I have a LinkedIn profile, a personal Facebook account & my clinic has a Facebook page.

7. Has social media affected how you practice rheumatology? If so, how?

Yes, I actually have a circle of international rheumatologists that I can now rapidly communicate with & get help from.

I have also learnt more about what patients think and feel, and I think that in turn improves how I interact and treat my own patients.

In my clinic, I believe that I do good work and help people. With social media, I can extend this. My interactions can potentially help many more people. This does empower me, and at the same time, creates a clear sense of responsibility.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?


Attempting to write 2-3 posts a week.

Quoting the site, my reason for blogging:
Sadly, there is a general lack of awareness and misinformation about Arthritis & related Musculoskeletal diseases. This blog does attempt to correct this. In addition, we discuss good health & rheumatology in general. 

bjcconnectedcare.com now attracts over 3000 unique visitors a month so that motivates me to continue


Name: Dr. Philip Robinson
Twitter: @philipcrobinson

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

I started medical school at the age of 17 (as is the way in the undergraduate medical system in New Zealand), I finished and trained in internal medicine and rheumatology, and became a consultant/specialist in 2010. I thought I wanted to be a pharmacist, but on getting to university medicine seemed much cooler, so I decided to do that. I was the last one into my medical class, so by the skin of my teeth.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

I live in Brisbane, Australia, where I was working seeing patients and doing research. If you want to visit Australia, I would be the Great Barrier Reef, Uluru (also called Ayers rock) and also visit the exciting contemporary city of Sydney. If you were to ask me where to go in New Zealand, (I am a New Zealander) then I would say the Bay of Islands in the north, with beautiful bush, inlets and history, the Tongariro plateau in the middle of the north island for skiing, climbing, walking and sightseeing, Rotorua for a cultural and geothermal experience, and the bottom of the South Island where Queenstown is and skiing, white water rafting and other adventure sports are. Lastly Wellington, which is a small capital city of only 300,00 or so, which has the greatest coffee in the world and interesting art and people.

3. What languages do you speak?


4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

Australia has great access to biologics (7 for RA), compared to NZ (only 2 for RA), the difference is based on a single public payer in each country with differing thresholds for paying for things based on both cost, budget and cost-effectiveness assessments. The medicare system in Australia supports many people to see private rheumatologists, and as such about 80% percent of people see private rheumatologists. This has advantages and disadvantages, but it means combined research/clinical jobs in hospitals are difficult to secure (and fund) and as such research in clinical rheumatology is held back in my opinion.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

I like to cycle for fitness.

6. What types of social media do you use most frequently? Which are the most useful?

I use Twitter for interacting about professional/rheumatology topics, and I use Facebook to keep track of friends. FB really is just for making sure I don’t lose contact with people. I think Twitter is much better and more up-to-date and accessible. I use Twitter daily.

7. Has social media affected how you practice rheumatology? If so, how?

It has made me aware that there are many people who source their information from the internet, and often act upon it without hesitation (they tell me this in clinic), this in empowering for patients only if they have the right sort of information in my opinion.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

No, I don’t have a blog because I don’t think I would time to post regularly on it (I am trying to finish a PhD).

My PhD is on the genetics of ankylosing spondylitis, specifically on a gene called ERAP1 which edits what antigens are shown to the immune system. I am using mostly computational/statistical genetics, but also doing laboratory immunology to determine the functional consequences of the genetic changes associated with AS. 


Name: Dr. Carlo V Caballero
Twitter: @carvicab
Blog: phdciencia.blogspot.com

1. Briefly tell us about your background/training in medicine. Did you have any prior career before/outside medicine?

My dad was a Pediatrician. I am Internist and Rheumatologist now for 20 years. I also studied health care management because a law in our country similar to Obamacare , then studied medical ultrasound to improve my skills reviewing patients and now doing a PhD in health communication because I love the possibilities of Social Media.

2. Where are you located? If someone were to visit from another country, what 2-3 things would you want them to see or do where you live?

Barranquilla, Colombia. The corner of South America.

1. Happiest country of the world and Barranquilla is the happiest City in the Country. So, the people.

2. Second biggest carnival in the world just after Rio de Janeiro. It’s a masterpiece of UNESCO because a great diversity. So, the carnival in february its a most.

3. 1 and a half Million people, 4th largest city in Colombia. Its 5 times a port (air, land, river, sea and communications). Largest city at Atlantic Coast and 2 and 15 minutes by airplane from Miami (We are close)

3. What languages do you speak?

Spanish and English

4. Is there anything unique about practicing rheumatology where you live (advantages, difficulties, etc)?

We have to do everything. In the mornings I am a Associate Professor of Medicine at a University Hospital. I attend also patients there (4 times a week), teach and do research. In the afternoon my private practice (patients all weekdays) and twice a week I have another consult in a clinic with associated rheumatologist.

I wake up early (5-5-30 am) and finish late (7-8 pm) everyday.

5. Any interests or hobbies outside of rheumatology that you would like to mention?

Tennis (club player), try to play 3 or 4 times a week (weekends for sure, Fridays in the morning and another day in the week). Writing and reading about everything and not just medicine also its a kind of hobby .

6. What types of social media do you use most frequently? Which are the most useful?

Twitter, Google Plus, Facebook, LinkedIn and recently also Pinterest. Twitter its a great news feed, love hangouts and communities features in Google plus, very social in Facebook and work and field connections in LinkedIn. So each one counts in some way. Using Pinterest for quotes and boards for patients.

7. Has social media affected how you practice rheumatology? If so, how?

Most important to me is that my practice is updated with current trends in the Rheumatology World being in a ¨Third world country.¨ And my colleagues, students and patients know that.

8. Do you have a blog? If so, how often do you blog? What do you try to write about?

Yes, about Medicine, Rheumatology, medical Education and Web 2.0. I blog as often I can and have something to tell (at least 1 post a week is current goal, mostly each 2 weeks)

9. Anything else you would like to say that I wouldn’t know to ask about?

I see Social Media as my Personal Learning Enviroment. Learn and engage with so many intelligent people around the world. It’s a big change. No barriers for knowledge.


Thanks to everyone who has helped on this project. More to come…

The Worldwide Community of Rheumatologists (Part 1: Introduction)

Paul Sufka

2012-11-14 14.13.59

Minneapolis, November 2012

“When you give everyone a voice and give people power, the system usually ends up in a really good place.” – Mark Zuckerberg

My first major realization of the enormous potential for social media in medicine was at the first rheumatology tweetup at the ACR meeting in Atlanta in 2011. During this meeting, I had made the conscious decision to (gasp) attend a few less lectures, and get out and meet people. During this time, I was able to meet a number of amazing people, many who have become more than just a contact with a profile picture and random 140 character messages, but colleagues and friends that I frequently interact with.

Interactions within social media have benefited my own continuing medical education far beyond what I could have learned by any other method. Although it might seem somewhat counterintuitive at first, anyone not using social media to keep up with medicine is at a significant disadvantage in this aspect. Why? Because a well-built social community will help do two very important things that you cannot do alone:

  1. Filter the most important information to you. What tends to show up frequently are the important journal articles, case reports, or just the best random and interesting things. The best questions that people are asking show up. I can’t think of any more useful single source of information. If it turns out that what is showing up doesn’t suit your interest, you can modify your network, but you have to remember that you also need to…
  2. Avoid being stuck in an information silo. If you’re never made aware of innovations going on in other areas, and you’ll never be able to apply them to your own life and practice. Social media is great at finding the best things in other fields that might apply to what you’re doing, and bringing them to you.

Brian Reid  (@brianreid) said it best on this Google Plus post on why Twitter is Important:

If your perception of Twitter (or Facebook or Usenet or Google+ or whatever) is as a broadcast tool, you’re probably never going to be entirely happy. If you view it as a way to join/build communities, you’ll be blown away.

Communities that are built on social media can expand in two directions. The most common way is to expand wider (follow more people, gain more followers): this way is relatively simple. The other way, is to look deeper: this is true networking.

Over the next few posts I plan to take a deeper look at some of the most active rheumatologists in the worldwide social media community. I hope that this will expand our community both wider and deeper.


An Update on Gout Management

Paul Sufka

Below is a reprint of an article I wrote for Just Joints, an online newsletter for health professionals distributed by the Arthritis Foundation Upper Midwest Region. This article will be posted in the archives eventually, but be sure to check out the other articles in this series. 

Also, be sure to check out Episode 2 of The Rheumatology Podcast, where we discuss an article looking at starting allopurinol during acute gout attacks, as well as some of our other experiences with gout. 

The incidence of gout has risen dramatically in the U.S. population, likely driven by the increased incidence of comorbid risk factors that include obesity, diabetes, chronic kidney disease, cardiovascular disease, and hypertension. Despite advances in current therapies for gout that can prevent unnecessary joint damage, tophi, and recurrent flares, many patients remain undertreated. In October 2012, the American College of Rheumatology (ACR) released guidelines on the  management of gout in two parts. This article will briefly review part one of the recent ACR guidelines, which focus on nonpharmacologic and pharmacologic management of hyperuricemia, which is often misunderstood and mismanaged, but likely plays the biggest role in long term control of gout.

Beginning with focus on patient education on diet and lifestyle changes, most physicians are aware of recommendations on the avoidance of organ meats in the management of hyperuricemia, and are also aware of limiting servings of seafood, beef, lamb, and pork. Avoidance of alcohol, especially beer, is also widely recognized. Newer recommendations that clinicians might not be aware of are to avoid foods and beverages containing high-fructose corn syrup, which has recently been associated with gout.

One of the most important parts of the recent guidelines is the recommendation to lower serum uric acid levels to less than 6 mg/dl at a minimum, and to less than 5 mg/dl in more severely affected patients, such as those with tophi present. Initial treatment of hyperuricemia should begin with one of the xanthine oxidase inhibitors (XOI), typically allopurinol. The initial allopurinol starting dose recommended was 100 mg daily in patients with normal renal function (50mg daily in stage 4 or higher CKD), which needs to be titrated upward until uric acid is at target. Failure to titrate the dose of allopurinol until uric acid levels are at goal is a common mistake in the management of gout.

Some physicians might be undertreating hyperuricemia over concern regarding side effects when increasing the dose of allopurinol, stopping long before reaching the maximal FDA approved dose of 800mg per day. Even in the setting of CKD, with proper monitoring for toxicity, studies have shown that allopurinol doses can safely be increased above 300mg per day, which is also pointed out in the recent recommendations. There are certain patient populations who are considered high risk of severe allopurinol hypersensitivity reactions, especially Koreans with CKD, and those of Han Chinese or Thai descent, and these patients should be screened for the HLA-B*5801 allele prior to starting allopurinol, which is associated with increased risk of hypersensitivity in these groups.

The newer XOI, febuxostat, is typically reserved for patients who have experienced adverse events from allopurinol, or have not achieved uric acid target despite maximal doses of allopurinol. Additional uric acid lowering therapy with uricosuric agents, typically probenecid in the U.S., is advised in patients who do not reach target uric acid levels with an XOI, given they do not have contraindications to these agents such as nephrolithiasis or significant renal impairment. A newer agent given intravenously, pegloticase, which is a recombinant uricase that metabolizes uric acid, can be given to patients with refractory disease.

Part two of the recent gout guidelines give advice on prophylaxis for patients recently started on uric acid lowering therapy to prevent attacks, usually with colchicine, and also discusses management of acute gout flares. Current knowledge of therapeutic strategies for gout has become increasingly important, especially as we are likely to see more patients with this condition in the upcoming years.

The Rheumatology Podcast is Now Available

Paul Sufka

“Real Artists Ship” – Steve Jobs

 “Don’t let the perfect be the enemy of the good” – Voltaire

The Rheumatology Podcast, hosted by Michael Laccheo, Suleman Bhana, and myself  is now available on the website. Update: Now available in iTunes! We also have a Twitter feed @TheRheumPodcast that we’ll be using for updates as well.

This is an initial venture into podcasting for all three of us, and we’re happy with how the first episode turned out. We’re hoping that it will only improve over time as the show evolves and will be as educational for our listeners as it already has been for us.

Please take a listen and let us know any comments, suggestions, or encouragement that you have. We’ll do our best to respond or incorporate any great ideas that we can.

At the time of this posting, plans are well underway for episode 2, with plans to discuss a specific article (to be revealed soon, so that listeners can read it prior to the episode), more discussion on the the use of social media in medicine, and other various topics in technology and rheumatology.

Announcing – The Rheumatology Podcast

Paul Sufka

I’m proud to announce, that along with co-hosts Dr. Michael Laccheo and Dr. Suleman Bhana, that the inaugural episode of The Rheumatology Podcast will be released early this next week.

In the first episode, we discuss a bit about who each of us are, electronic medical records, misunderstandings about rheumatology and rheumatologists, social media use in medicine, a few of our takeaways from ACR 2012, and more.

I’ll post links to the first episode when available both here and on Twitter (@psufka).

More details are currently being added to The Rheumatology Podcast website as they become available.

Applying the Pareto Principle (80/20 Rule) to Rheumatology

Paul Sufka

“If you can’t explain it to a six year old, you don’t understand it yourself.” ― Albert Einstein

Update 1/4/2013: This post was republished today in the ACP Internist blog

Since entering the field of rheumatology, I have too frequently heard comments from clinicians admitting their lack of knowledge and understanding in the field of rheumatology.

I understand why rheumatology has gotten a reputation as being difficult. The basis for the understanding of rheumatic conditions is the immune system, where our knowledge is becoming ever complex. Many of the rheumatic conditions are uncommon, so clinicians are less comfortable recognizing and treating them. To make things worse, we order a number of oddly named antibodies and use medications that affect the immune system in strange ways.

Fortunately, the basics of rheumatology are not extremely difficult to understand.

The Pareto Principle (80/20 rule)

The Pareto Principle says that 80% of the results come from 20% of the effort, knowledge, or resources. This rule has been shown effective  in numerous fields outside of medicine, especially business and finance, and can be used as an effective technique to approach any difficult topic.

With this in mind, I’ll try to focus on the 20% of rheumatology that I think is the most high yield for those outside of rheumatology to understand.

(Sorry fellow rheumatologists, this post isn’t intended to teach you much of anything, but might be helpful when you give guidance or mentor others. I would GREATLY appreciate any additions or corrections in the comments section below).

The unifying mechanism in the rheumatologic diseases is inflammation

Recognition of inflammation is really the first step in thinking about the rheumatologic diseases. With few exceptions, the first thing I’m trying to decide with every new patient I see in the office is whether an inflammatory condition is present, or not.

Recognition of inflammation goes back to the very basics of what we are taught in medicine: the history and physical exam

Joint pain is an extremely common complaint. Being able to differentiate inflammatory from non-inflammatory joint pain is likely the most high yield knowledge in rheumatology. Differentiating these two processes is important because the treatment strategy will vary greatly between the two types.

Taking a pain history: OPQRST

Many of us are taught early in our training the mnemonic “OPQRST” to remember the components of a taking a history. While likely very basic, this is worth reviewing, as details discovered here can greatly change suspicion for inflammation later on.

  • Onset – When did the symptoms start? Rapid or slow onset?
  • Provoking/palliating factors – How are the symptoms affected by use? What about rest? Do anti-inflammatories or other medications help? What else have they tried?
  • Quality (description) of the pain – Dull, aching, stiffness, burning, etc?
  • Regions/radiation – What joints or other areas are involved? (Remember to ask about the neck and back) Does the pain radiate from one area to another?
  • Severity – Generally rated on a scale of 0-10
  • Timing – Constant or intermittent symptoms? Does it change throughout the day (morning stiffness)?

In terms of differentiating inflammatory from non-inflammatory causes, the most helpful are the provoking/palliating factors, and the timing of the symptoms. Inflammatory arthritis is typically associated with pain that is worst in the morning or after resting, with stiffness typically lasting 30-60 minutes or more, and improves with activity.

The complete review of systems: finding the puzzle pieces

The next most powerful tool that rheumatologists use is the complete review of systems. Lack of comfort with what questions to ask,  or the feeling that this takes too much time, is likely another reason that many clinicians are uncomfortable with rheumatology. In reality, the puzzle pieces found in the complete review of systems is often where the bigger picture starts to come into place. Feeling overwhelmed? Use the patient as a guide, starting head to toe, to help remember features to ask. Use a checklist if needed at first, or consider using this rheumatologic patient history form from the ACR.

The cardinal signs of inflammation on exam: if you don’t know what to look for, you won’t find it

Most of us are aware of the five cardinal signs of inflammation, but might not have been taught some of the details to look for:

  1. Dolor (tenderness on palpation)
  2. Calor (heat): The joint is typically cooler than the surrounding tissues.
  3. Rubor (redness/erythema)
  4. Functio laesa (loss of function): Typically decreased ROM due to tenderness. If joint function is normal, consider surrounding tissues as the cause of pain. This can be particularly helpful in differentiating cellulitis and/or bursitis from joint inflammation and septic joints.
  5. Tumor (swelling):
  • Look for loss of “dimples” around the joint & decreased skin lines over the joint
  • Feel for the edges of the joint to feel “boggy/squishy” or less distinct
  • Feel small joint swelling/effusions by pushing with one finger & sensing with the other

The Rheumatology Image Bank, especially comparing images of rheumatoid arthritis and osteoarthritis is great resource to look further at these details.

A more detailed resource for rheumatologic exam tips can be found here: http://physicalexamination.org/?q=node/56

Palpating joint inflammation: practice, practice, practice!

With enough practice, you can learn to palpate synovitis (I have taught medical residents to do this in clinic over the course of a morning). Practice palpating your own joints (assuming they are normal), especially the hands. You typically should easily be able to feel the edges of the joint lines, with only the sense of a normal, thin layer of skin separating the joints from your fingers. If you feel boggy/squishy or less distinct joint lines, along with other features from above, inflammation is more likely.

When to order an ANA

This article: Cleveland Clinic Journal of Medicine 2002; 69(2):143-146 (full text and pdf available without subscription) is a great review of when to order an ANA for our patients.

In summary an ANA should be ordered when the pretest odds of autoimmune disease are high, which is based on findings from our history and physical, summarized  in the table below:

Rheumatoid factor (RF): consider causes other than rheumatoid arthritis

Similar to the ANA, the RF should be ordered when the pretest odds of rheumatoid arthritis are high, which requires joint inflammation/synovitis to be present, and increases with the number of affected joints (refer to this excerpt from the 2010 ACR/EULAR RA Classification Criteria for Rheumatoid Arthritis; see also: link to complete pdf article). When suspicion of rheumatoid arthritis is high, typically an anti-CCP is also ordered.

Keep in mind that a positive RF is common in a number of other rheumatic disorders (Sjogren’s syndrome and cryoglobulinemia being most common, but the other connective tissue diseases such as lupus to lesser degrees).

The most common other condition that causes a positive RF is hepatitis C infection, which must be ruled out when a positive RF is detected (additionally, hepatitis C infection is associated with an inflammatory arthritis).

Other conditions associated with positive RF include hepatitis B, lymphoproliferative disorders, malignancy, chronic infections, inflammatory lung conditions.

Common mistakes in gout management

When I asked for suggestions for high yield rheumatology topics on Twitter, gout quickly came up multiple times. Since the incidence of gout is on the rise, likely related to increased risk factors (obesity, diabetes, chronic kidney disease, cardiovascular disease, and hypertension), knowledge of appropriate management will only become more important.

Gout management is divided into acute management (typically treated with prednisone; colchicine, or NSAIDs) and management of hyperuricemia.

The management of hyperuricemia is where most errors in management occur, especially failure to lower the uric acid to 6.0 or less. In most patients, this is accomplished by titrating the allopurinol dose every few weeks until this is achieved, and many clinicians fail by never titrating to a high enough dose to reach this goal. Additionally, most patients are placed on prophylaxis against attacks when first initiating medications to lower uric acid, since risk of flare is highest during this time. These topics are covered nicely in a two part update, published in October 2012.

In closing, I hope this serves as a good starting point for clinicians to become more comfortable in the field of rheumatology. I invite my rheumatology colleagues to post additions, corrections, and any comments below.