“Make no small plans” — attributed to Daniel Burnham
The field of medicine can be isolating in many ways — especially in that it can be difficult to identify peers who have had similar specialized training, and are therefore going through similar difficulties.
After a recent discussion on Twitter, we’re starting a private Rheum-mastermind group on Slack.
According to wikipedia, a mastermind group is “ a peer-to-peer mentoring concept used to help members solve their problems with input and advice from the other group members.”
A few initial thoughts at the time of launch:
1. This will be a private group, hopefully to allow people to ask questions more openly about difficult topics — career advice, practice management, lifestyle, job hunting.
2. Initially, I don’t think anything will be off limits (expect a need to respect HIPAA privacy).
3. I would highly encourage the use of direct messaging within Slack, especially if you connect with another member. Better yet, connect via phone or video/FaceTime/Skype.
Don’t worry If you’re not familiar with Slack. The built in tutorials are extremely helpful.
I’ll send out direct messages via Twitter to everyone that has shown interest. If I miss you, feel free to @ or DM me — I’m @psufka on Twitter.
The life wisdom shared by the brilliant writer and neurosurgeon, Dr. Paul Kalanithi, in the face of his own stage IV cancer diagnosis makes it a book that every human should read.
My favorite quote from the book, when Paul and his wife, Lucy, are considering whether to have a child in the face of his diagnosis is one of the few quotes that brings me to tears:
“Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?”
”Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.”
Physicians generally don’t get enough training in the major meta-like skills, and while there are other great books on negotiation (Getting to Yes, Secrets of Power Negotiating) that are also worth reading, these often feel too theoretical to apply to daily life.
In the case of Never Split the Difference, author Chris Voss is a former FBI hostage negotiator that teaches tactics are refined enough for use in life and death situations (the situations he describes in the book are worth reading on their own), but work just as well for negotiating your cable bill.
What books have you read more than once? Let me know in the comments below or else let me know on Twitter @psufka.
A common frustration expressed by patients in my clinic with rheumatoid arthritis (and other types of inflammatory arthritis) is that their family and friends have very little grasp of what is occurring to them, often with significant misconceptions.
Family and friends want to help, but struggle to understand what they can do, feeling lost. They try to be sympathetic to your pain, but have zero idea how to help other than lifting heavy things and opening jars.
This guide is intended serve as a resource for patients to help their friends and family understand just enough of the medical aspects of arthritis to appreciate the symptoms they’re having, how it affects their daily lives and emotions, and the best ways to help.
Misconceptions about rheumatoid arthritis
That someone with rheumatoid arthritis is doing well because they don’t “look sick.”
People with chronic conditions such as rheumatoid arthritis often learn to hide their symptoms and do their best to carry on throughout their day. Just because they look well, doesn’t always mean they are free of pain, fatigue, or other symptoms.
That symptoms of arthritis are limited to joint pain and shouldn’t make you feel tired, depressed, or helpless.
Because rheumatoid arthritis is a chronic, progressive condition caused by the immune system, and commonly causes more generalized symptoms (most commonly fatigue), and can occasionally affect internal organs (lungs are the most common organ effected).
That rheumatoid arthritis is just due to aging or other lifestyle factors, such as a “bad” diet or lack of exercise.
People of any age can be affected by rheumatoid and other forms of inflammatory arthritis, and as we’ll discuss below, we don’t completely understand what causes it. Also, while exercise and weight loss are important for everyone and help manage symptoms of rheumatoid arthritis, they do not treat the condition.
That people with rheumatoid arthritis are just treated with pain medications.
While pain medications are helpful to manage symptoms of rheumatoid arthritis, treating rheumatoid arthritis with pain medications alone will not prevent the immune system from causing damage to the joints and reduce inflammation in other parts of the body. Because of this, the main treatments typically used for rheumatoid immunosuppressive medications.
That you can just “fix” your arthritis by improving your diet or taking some supplement, or that it is caused by a “bad” diet.
Improving your diet (such as eating more whole, unprocessed foods and avoiding sugars) will usually make you feel better and is important for general health, but no specific diet or supplement will typically cure rheumatoid arthritis.
That people with negative labs cannot have rheumatoid arthritis.
Actually, about 20% of patients have negative rheumatoid factor (RF) and anti-CCP (a specific test for rheumatoid arthritis). The best way to diagnosis rheumatoid and other types of inflammatory arthritis is to see a rheumatologist who can do an exam to look for the type of joint swelling seen in these conditions, called synovitis.
What is the difference between rheumatoid arthritis and osteoarthritis?
We separate arthritis into two major types:
Inflammatory arthritis, which is caused by the immune system attacking the joints, causing inflammation and damage. The most common type of inflammatory arthritis is rheumatoid arthritis, but this group also includes psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, and lupus. Treatment of this type of arthritis is focused on reducing inflammation, often with medications that suppress the immune system.
Non-inflammatory, which is often referred to as osteoarthritis or degenerative arthritis. This type is typically caused by breakdown and loss of cartilage in joints. There is no role for using medications that suppress the immune system for osteoarthritis.
What causes rheumatoid and other types of inflammatory arthritis?
Unfortunately, we don’t have a great answer yet.
Normally, our immune systems do a good job protecting us from anything harmful in our environment, while recognizing that it shouldn’t attack parts of itself. Understanding how the immune system works and what happens when things go wrong has shown to be complex beyond our wildest imaginations. Researchers all over the world are working on this.
What we do know about the cause of rheumatoid arthritis:
Something triggers the immune system into attacking the joints. We don’t know exactly what these triggers are, but do know some of the risk factors (below).
This results in the immune system to be confused into attacking the joints.
The immune system is very powerful, which results in inflammation and damage to joints.
Because the immune system is present throughout the body, there are often systemic effects (outside of the joints).
Risk factors for developing rheumatoid arthritis
We also know a number of factors that seem to increase the risk of developing rheumatoid arthritis, such as female gender, family history, smoking, and obesity. There have been genetic factors identified that play a role in rheumatoid arthritis, especially in smokers. The role of an infection as a trigger has been hypothesized, especially periodontal (gum) disease or gut microbiome, but is still unproven.
How is rheumatoid arthritis treated?
DMARDs: The Mainstay of Controlling Inflammation in Rheumatoid Arthritis
The primary treatment of rheumatoid and other types of inflammatory arthritis are medications called ‘DMARDs’, which stand for ‘Disease Modifying Anti-Rheumatic Drugs’. These medications are the focus of treatment because they are able decrease inflammation in ways that are able to prevent joint damage from rheumatoid arthritis over the long term (which is why they are called ‘Disease Modifying’).
Methotrexate is the most common first-line DMARD prescribed, and is a strong anti-inflammatory and mild immunosuppressive. Other commonly used DMARDs of similar strength include leflunomide (Arava®) and azathioprine (Imuran®). Each of these medications have the potential for side effects, which most commonly include increased risk of infection due to immunosuppression, gastrointestinal upset, or generally feeling ill. Each of these medications also require frequent blood monitoring to watch for lowering of blood counts, liver inflammation, and kidney function.
Milder cases of inflammatory arthritis might be treated with medications that do not cause immunosuppression, which include hydroxychloroquine (Plaquenil®) or sulfasalazine.
The majority of patients with rheumatoid arthritis will actually require two or more DMARDs to control inflammation.
Unfortunately, there is no single ‘miracle drug’ or treatment that will cure rheumatoid arthritis — at best, these medications will keep people in remission, and need to be taken long term, which means frequent follow up with physicians and lab monitoring.
When inflammation is not controlled with first-line oral DMARDs, if patients are not able to tolerate them due to side effects, then newer biologic medications are often used. These are typically taken by subcutaneous injection or given intravenously (IV). These medications are work by targeting specific proteins in the immune system that cause inflammation. Currently, biologic medications are very expensive, costing thousands of dollars per month, but they are often highly effective (but not necessarily 100% effective as it would appear on commercials). Despite concerns about potential side effects, they are typically well tolerated. The most common side effects of this entire group of medications are increased risk of infection and injection site reactions (redness and swelling at the area the medication is injected under the skin).
Considering the Risks and Benefits of Treatments
In general, the risk of NOT treating rheumatoid arthritis outweighs the risk of treatment. Without treatment, there is an extremely high risk of damage to joints, leading to pain and disability.
People generally worry about damage to their liver and kidneys from medications used to treat rheumatoid arthritis, but this is generally avoided by frequent lab monitoring and close follow up with your physician.
When considering risk of infection from treatments used for rheumatoid arthritis, a few things to keep in mind:
There is actually increased infectious risk due high disease activity related to rheumatoid arthritis (i.e., increased infectious risk from NOT treating rheumatoid arthritis).
The majority of infectious risk from medications in the treatment of rheumatoid arthritis is attributable to prednisone, rather than DMARDs or biologics.
Patients are typically screened for underlying risk of tuberculosis, hepatitis B and C prior to starting biologics, and also typically have their vaccinations updated (such as influenza and pneumococcal vaccines).
Additional Ways to Control Inflammation: NSAIDs and Prednisone
From a medication standpoint, the most commonly used additional treatments to control inflammation in rheumatoid arthritis are NSAIDs (such as ibuprofen or naproxen), or steroids such as prednisone. Either of these can be helpful, but each come with risk of potential side effects. Unfortunately, neither of these have been shown to prevent joint damage from rheumatoid arthritis, which is why they are not considered first line treatments. Since NSAIDs and prednisone work quickly, they are frequently used to control symptoms while waiting for slower-acting DMARDs to take effect.
NSAIDs
Are typically mild to moderate anti-inflammatories.
Side effects include stomach upset and risk of bleeding ulcers, kidney problems, high blood pressure or heart problems.
Because there are many reasons that people cannot take NSAIDs, they should ask their doctor before starting them.
Prednisone
Is a moderate to powerful anti-inflammatories (depending on the dose).
Increases risk of infection.
Can affect your mood in many ways, such making you jittery, anxious, and can affect sleep.
Can increase appetite and make people prone to gaining weight.
Has a number of other side effects that might not be obvious to the observer, such as headaches, raising blood sugar or blood pressure, fluid retention, blurry vision and cataracts, and thinning of the skin.
Treating Flares of Arthritis
Frequently, a “burst,” or short course of prednisone is used to treat a flare of arthritis, which often exacerbates the pain and difficulty moving that the person is having with some of the side effects of prednisone noted above, such as feeling more anxious, more trouble sleeping, and increased appetite.
The Role of Supplements
Compared to DMARDs, generally supplements play a minor role in the management of rheumatoid arthritis. This is because no supplement has yet been shown to prevent joint damage.
Despite what you might read in other articles or see on TV shows, the latest natural supplement or remedy is not likely to be a cure-all for inflammatory arthritis. Unfortunately, these are generally just marketing hype or used to draw viewers to an article or show.
This being said, a few supplements, such as turmeric, may be helpful in managing symptoms or possibly reducing joint inflammation. Because supplements are not as well studied as medications obtained from pharmacies, we often don’t know as much about side effects or interactions with medications. For this reason, always discuss any supplements you are considering or currently taking with your doctor.
Other
Besides medications, people with rheumatoid arthritis might need other types of treatment, such as help from physical therapists or occupational/hand therapists.
Exercise and stretching are important parts of treatment for arthritis, and really should be done as regularly as one would take medications. Depending on how well joint inflammation is controlled, the ability to exercise might be significantly limited due to pain, stiffness, or fatigue.
People may need devices to help with mobility, such as a cane or walker, or even to make modifications to their home. Some patients may need a handicap parking permit.
Other symptoms associated with inflammatory arthritis
Despite the name, symptoms and involvement from different types of inflammatory arthritis are not always limited to the joints.
Rheumatoid arthritis can be associated with additional problems such as rheumatoid nodules (firm lumps under the skin, most frequently noted on the hands, feet, and elbows), lung disease, and dry eyes and mouth. Eye inflammation is seen in many types of inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and others). Most types of inflammatory arthritis have been linked to increased risk of cardiovascular disease (such as heart attack and stroke), and increased risk of bone fracture due to osteoporosis.
Arthritis affecting daily life
Inflammatory arthritis affects patients in ways that are not obvious to the people around them, which include:
Pain and stiffness causing loss of function
While one would assume that pain and stiffness are the most obvious symptoms of arthritis, they also seem to be the most difficult symptoms for others to notice.
Chronic pain is different from acute pain, since the person who has it is typically dealing with some degree of it all of the time. Because of this, the person doesn’t always “look” like they are in pain and may be doing their best to hide the fact they are dealing with pain and other symptoms. Often, the person may say that they are doing fine, which may mean that they are dealing with their usual amount of chronic pain.
Fatigue.
The next most common symptom people with inflammatory arthritis deal with is fatigue, which is also one of the most difficult to explain to other people, since it is another invisible symptom.
For some people, fatigue will come and go with with activity of their joint inflammation, and many others will have fatigue on a daily basis.
A frequent way to explain chronic fatigue is Spoon Theory, which explains the “reduced amount of energy available for activities of daily living and productive tasks that may result from disability or chronic illness. Spoons are a tangible unit of measurement used to track how much energy a person has throughout a given day. Each activity requires a given number of spoons, which will only be replaced as the person “recharges” through rest.”
Feelings of frustration, depression, and helplessness.
The uncertainty that results from a chronic condition can bring a person down mentally, not knowing if simple tasks such as getting out of bed or getting ready for the day will be difficult or painful. Often enough, the person with arthritis is frustrated by the fact that they have to be extra careful to avoid exposure to infections from other people, or that they can’t have a glass of wine or beer with you because it interacts with the methotrexate or another medication that they’re taking. Over time, these feelings can result in depression or other symptoms that require the help of a medical professional.
Side effects of medications.
On top of everything else, patients often have to deal with side effects of medications to control their condition. As above, the side effects will vary depending on the treatments being used, but nausea/stomach upset, headaches, or generally feeling ill. Increased risk of infection is always a concern. If they’re using prednisone, weight gain can be an issue, and can also affect their mood.
Listening: The Most Important Way to Help
The most important part of helping your family member or friend with arthritis is to start by actively listening to them.
Many people with inflammatory arthritis find it difficult to share and relate how they’re feeling or how they need help.
Things you can do to improve how you help by listening:
Give the other person your complete attention. If they need your help, make sure you block off enough time to have a complete conversation and mute your phone so that you’re not distracted. Listen until they’re done talking and ask questions if you don’t understand or can’t relate.
Ask how you can help before providing unsolicited advice or feedback.
Things not to do: Don’t interrupt. Don’t judge. Don’t change the subject.
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Painting: Renoir, Pierre-Auguste. (1880-1). Luncheon of the Boating Party, Washington DC: The Phillips Collection.
“I cannot remember the books I’ve read any more than the meals I have eaten; even so, they have made me.” ― Ralph Waldo Emerson
I initially set myself the goal of reading one book per week for 2016, and although a pair of books I’ll mention below kept me from reaching my goal, I was able to read (and thanks to Audible, listen to) a ton of great books this year. (Follow what I’m reading on Goodreads). Below are the best five books (and one documentary) that I came across this year.
Fiction
I’m not typically a big fan of fiction, so I only have one suggestion here. I heard Chris Sacca recommend How to Get Filthy Rich in Rising Asia by Mohsin Hamid on two separate occasions, so I had to check it out. For this one, I listened to the Audible version, since it was narrated by the author. This is a novel written in the style of a self-help book, giving a dark, first-person account of a nameless poor boy who becomes a wealthy tycoon.
Non-fiction: History and the Future
Sapiens: A Brief History of Humankind by Yuval Noah Harari followed by Superintelligence: Paths, Dangers, Strategies by Nick Bostrom. These are the two long, dense books that kept me from my goal of a book per week, but it was completely worth it. Sapiens (464 pages) gives an overview of human history through the perspective of four different revolutions: cognitive, agricultural, and scientific, and will improve your understanding of how Homo sapiens have been able to survive, thrive and conquer. Superintelligence (390 pages) takes a look at the current state of artificial intelligence, how a superintelligenece will eventually form (it’s inevitable), and ideas on how we should develop these systems to maintain control.
Non-fiction: Personal Development
Extreme Ownership: How U.S. Navy SEALs Lead and Win by Jocko Willink and Leif Babin and Ego Is the Enemy by Ryan Holiday. In the author’s own words, Extreme Ownership: “explains the SEAL leadership concepts crucial to accomplishing the most difficult missions in combat and how to apply them to any group, team, or organization.” I suggest pairing this book with Ego Is the Enemy, which uses underpinnings in stoic philosophy and well selected stories to teach the reader to: “Forget yourself and focus on the work. Be humble and persistent. Value discipline and results, not passion and confidence. Be lesser, do more” (from Derek Sivers editorial review).
Documentaries
Somm (available on Netflix and iTunes) follows four people trying to pass the Master Sommelier Diploma, a title currently only earned by 233 people in the world. Beyond the wine knowledge displayed in this movie, this documentary is also a look at what it takes to become the best of the best in a field, and resembles Jiro Dreams of Sushi in the depth of mastery displayed.
Image by AaronMosh7 (Own work) [CC BY-SA 3.0], via Wikimedia Commons.
“Consider getting smaller in order to get bigger.” — Sir Richard Branson
Many people feel a bit of overwhelm at the idea of using social media during a medical meeting. These same people are recognizing the many benefits of using social media: connecting with others, actively learning, and promoting their work.
(This post is going to focus on using Twitter efficiently, but if you’re interested in digging deeper into what you can do, take a look at my talk from the 2016 ACR Program Directors’ Conference: Using Twitter in Medical Education and links to prior social media summaries from ACR 2014 and ACR 2015.)
Using Twitter during the meeting doesn’t have to be difficult or significantly time consuming.
After you’re following everyone at the meeting, use the Nuzzel website or app (iOS | Android) to catch up on highlights from people you’re following from the last 24 or 48 hours, (which shows the most important tweets in your timeline, according to RTs and likes). It can also send you a daily email that you can review later. (For more details, see my prior post about how I keep myself on a low information diet using Nuzzel).
If you’re using a laptop at the meeting, try using tchat.io on your web browser to more efficiently follow and participate in the #ACR16 hashtag in real-time. Bonus: tchat.io will automatically include the hashtag in your tweets so that you’re included in the conversation.
“Tell me and I forget, teach me and I may remember, involve me and I learn.” — Benjamin Franklin
The ACR Annual Meeting (#ACR16) is such a huge event that it’s worth your time to spend an hour or two planning your time at the meeting. (I highly suggest Dr. Philip Gardiner’s post: How to make the most of a medical conference….)
At this point, I generally attend sessions that I want to talk to the speaker afterwards, and make note of other sessions that I want to watch later online through SessionSelect.
Besides this, I suggest scheduling some time every day to exercise during the meeting. Really: put it in your calendar. (Alternatively: schedule a caffeine nap.)
Here’s my tentative #ACR16 session schedule:
Saturday, November 12:
8am–4pm: ACR Review Course. Always a well selected group of topics relevant to clinicians.
7:30–8:30am: Year in Review. Summary of the best in clinicial and basic science research of the last year. Happy to see Dr. Ingrid Lundberg from the Karolinska Institutet will be giving the clinical portion this year.
9:00–11:00am: I’ll be helping present #RheumJC’s poster #1145: #Rheumjc: Impact of Invited Authors on a Twitter Based Rheumatology Journal Club. Check RheumJC.com on the day of the poster for a downloadable pdf of our poster. Better yet: come say hi to the #RheumJC team.
2:30–4:00pm: Innovative Solutions to Deliver Care. Two interesting back to back lectures. The first, by Dr. Rafael Grossmann (@ZGJR), part of Singularity University’s Exponential Medicine and the first surgeon to use Google Glass during a live surgery. The second, by my friend, Dr. Irwin Lim (@_connectedcare), discussing his experiences with telerheumatology.
Official session overview:The tweet up is an informal event without an agenda organized by ACR members. It is an opportunity for members who engage on Twitter to meet face-to-face. All annual meeting attendees are welcome to participate. The tweet up is designed to facilitate personal connections within the international rheumatology community.
Twitter continues to be the gold standard social media tool for physician lifelong learning, which I’ve spoken about earlier this year at the 2016 ACR Program Directors’ Conference: Using Twitter in Medical Education.
The use of social media in medicine has continued to mature. Major medical meetings now have social media as a centerpiece for discussion, indexed on Symplur’s Healthcare Hashtag Project. Online journal clubs have organized, such as our very own #RheumJC, holding monthly sessions with participation of authors to directly answer questions about their articles.
There is a growing interest in documenting the use of Twitter at medical meetings. “Tweeting the meeting” has many benefits, including enhancing the educational experience of meeting attendees, disseminating content to those not in attendance (physicians, patients, general public and the media), and increasing the visibility of the medical organization. While still seen by many as frivolous, an increasing number of physicians and organizations understand the real value that comes from an active social media presence during conferences.
”What gets measured, gets managed.” – Peter Drucker
Despite being considered one of the techie people in the physician/rheumatology community and a self-proclaimed Apple fanboy, it might be surprising to know that I don’t own (or want) an Apple Watch.
But the main reason I don’t own any type of smartwatch is that I don’t see anything useful that they allow me to track.
When I look for things to track, I look for key performance indicators (KPIs): things that I consider modifiable activities, that when tracked or measured, correlate with improvement in specific goals.
With this in mind, I’ll start with a few of the more common activities that I don’t track (and why):
Steps per day. Although the recommendation to walk 10,000 steps per day is an arbitrary number, I do find that it is an excellent suggested baseline level of activity for most people. However, since I’m a fairly active person that exercises most days of the week (and even uses a standing desk at work and at home), I don’t find that this has any correlation with my fitness level.
Bodyweight. I’m fortunate enough that my bodyweight has varied little throughout my life. I credit this mostly to exercise (primarily strength training since my teenage years), along with generally watching my diet. Certainly, if my bodyweight would increase (especially in the form of adipose tissue), this would quickly become one of my KPIs.
Calories. In recent years, increased importance on the type of foods that we eat has been recognized. While the total energy that we consume certainly matters, the effects of different types of food also clearly play an important role. In other words, you would expect your body to react differently to 2,000 calories of pure sugar versus 2,000 calories of grass-fed steak.
Activities that I track (and how):
Heart Rate Variability (HRV). HRV is a measure of how much beat-by-beat variation occurs in your heart rate, which is governed by the balance of sympathetic and parasympathetic nerve activity. More simplistically speaking, HRV can give a sense of how much stress the body feels at a given time. (PDF of a review here). In a fully rested/low stress state, you should have a high HRV, and under conditions of high stress, you would expect your HRV to decrease. Increasingly, high level athletes are using measure of HRV to titrate their level of training for the day.
I use an app called HRV4Training (App Store) to track my HRV most mornings, which uses the iPhone camera and flash to measure your heart rate via plethysmography with surprisingly good accuracy (especially if used in a dark room). After this, your HRV can be viewed in the form of rMSSD (the unit by which HRV is calculated, called the Root Mean Square of the Successive Differences).
In my case, whenever my HRV rMSSD is above 80, I’m fairly well rested (which means I’ll probably do deadlifts that day).
I’ve found that my HRV seems to most strongly increase with the amount of perceived rest that I get, with frequent moderate-high level exercise, and with meditation. My HRV seems to decrease the most when I’m sleep deprived, when I’m sick (or feeling like I might be getting sick), or after overly intense exercise (especially too many deadlifts).
Exercise. I track exercise using a website called beyond the whiteboard, which is popular in the CrossFit community, and fits very well with the style of workout that I often perform. The site allows you to analyze your overall fitness level in comparison to other athletes who use the site, and also helps you identify strengths and weaknesses in your overall fitness.
Sleep. I have a Sleep Number bed that has built in sleep tracking, although I don’t find that it always correlates with my perceived level of rest. Sometimes, this is because I’ll fall asleep in my son’s room while putting him to bed, so the data is wrong (such as on Sunday of the picture below).
Meditation. Over time, I’ve come to find a great deal of benefit from meditation (and I’ll give Dr. Ronan Kavanagh credit for initially turning my onto the idea of it.) I currently try to meditate 10–20 minutes each morning using the Headspace app (Web | App Store), and have felt increased ability to focus and generally calmer.
Other: Mobility & Diet. I use an app called Way of Life (App Store) to get a big picture view of a few things I’m tracking, such as meditation and exercise, and other things I’m trying to watch, such as doing some mobility work (especially hips, ankles, and shoulders) most days. The app essentially allows you to check yes or no for each day, and encourages you to go on a streak of 3+ days.
