Speaking at HealthPartners Primary Care Update Conference

Paul Sufka

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

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

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

Download slides:

Other posts of mine that you may find helpful:

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

My WordPress Setup, Plugins and Writing Tools

Paul Sufka

Inside mbp

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

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

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

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

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

Two ways to run WordPress

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

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

 

WordPress Themes

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

WordPress Plugins

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

Security

Speeding up WordPress

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

SEO

  • WordPress SEO by Yoast – despite some Search engine optimization (SEO) being built into my Thesis Theme, I find that this plugin does a better job at optimizing searches for my name (which as a physician, is the result that I care most about). An alternative to consider (with overall easier setup) is All in One SEO Pack. While I haven’t compared my results with these two plugins directly, Yoast’s package seems to be more successful[Update 11/4/2014: Since updating from Thesis version 1 to version 2, I have disabled WordPress SEO by Yoast owing to some compatibility issues, and am using the SEO built into Thesis. It appears these issues have been addressed, but I currently haven’t done any of the fixes].
  • Google XML sitemaps – XML sitemaps are files listing your sites URLs with important information about each to search engines. Yoast’s WordPress SEO has this built in, which is likely adequate, but this plugin gives you more control.

Statistics

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

Backup

Other 

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

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

Editing Tools

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

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

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

Creating content

This is the hard part. I like WordPress founder Matt Mullenweg’s post suggesting that you “write for only two people”: yourself and “a single person who you have in mind as the perfect person to read what you write”. As such, this post was inspired by Dr. Rebecca Grainger looking for tips on starting a blog via Twitter. [Update 12/07/2014: Dr. Grainger (along with Dr. Eimear Savage) recently started a blog: 2xrheum: A rheumatology blog is born.]

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

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

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

Paul Sufka

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

[Update 10/11/2014: Excellent article from The New Yorker on the topic of Dunbar’s nunber: The Limits of Friendship)

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

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

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

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

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

And concluded that:

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

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

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

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

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

Paul Sufka

SF-tree2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Update 11/19/2014 – Links to related articles:

Social Media and the Tweetups at #ACR13

Paul Sufka

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks again!

#ACR13 TweetUp – San Diego

Paul Sufka

ACR tweetup400x400

Here’s the current plan for our social medial Tweetup for #ACR13 in San Diego:

*** updated 10/3/2013 with plan for lunchtime session at Maryjane’s ***

*** updated 10/26/2013: Twitter highlights from #ACR13 review course ***

This year, we’ll be having two events, in hopes that more people can attend.

This is an open event. Anyone interested can attend. You do not have to RSVP, but if you are planning or thinking of attending, please let me know so that I can try to give the venues an updated idea of how much space we might need.

Sunday October 27th – 6:00pm

  • Hennessey’s Tavern – 708 4th Avenue, San Diego, CA 92101 (Google map)
  • Approximately 11 minute walk from convention center.
  • There will be no specific end time to this event. If you’re running late and wondering if anyone is still there, feel free to message me at @psufka on Twitter. I’ll do my best to respond ASAP.

Monday October 28th – Lunchtime session – approximately 12:00-2:00pm

  •  Maryjane’s at Hard Rock Hotel San Diego -207 5th Ave, San Diego, CA (Google map)
  •  Across the street from the convention center

Blog posts from prior Rheumatology Tweetups:

 Some suggestions for planning and attending ACR (or other large medical meetings):

Can’t wait to see everyone there!

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Let me know if anyone has comments or suggestions? I’ll keep this post updated.

Also let me know if I’m missing links to other blog posts from other past Rheumatology Tweetups.

Welcome ‘The Rheumatologist’ Readers

Paul Sufka

MBP

“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

Nest

“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

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 “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).

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.