Rheumatology Journal Club

Most months we have a couple residents rotating with us on a Rheumatology elective.  As part of that month, we hold a journal club where each resident and the teaching attending presents an article. Here is what we discussed this month:

Askling et al. Cancer Risk in Patients With Rheumatoid Arthritis Treated with Anti-Tumor Necrosis Factor Alpha Therapies. Arthritis and Rheumatism. 2009; 60:11.

• Chosen by the attending. Supports the observations against increasing cancer risk over time with these medications.

Woodburn et al. A Randomized Controlled Trial of Foot Orthoses in Rheumatoid Arthritis. The Journal of Rheumatology. 2002; 29:7.

• Chosen by the podiatry resident. Orthotics are very helpful in RA but they need to be worn (pts wore them avg of 6 hours/day) and it is helpful to ensure someone skilled in orthotics and gait is fitting them.

Daimon et al. Nonspecific Interstitial Pneumonia Associated with Collagen Vascular Disease: Analysis of CT Features to Distinguish the Various Types. Internal Medicine. 2009; 48.

• Chosen by the prelim radiology resident. It’s hard to diagnose Rheumatologic conditions just by a CT scan. Score one for the H&P! However, CT can be an important piece of the equation.

Foodie Friday: Return of the carnivore (or, THE BEST beef stew)

Just a few short months ago I really did eat a mainly vegetarian diet. On October 1st, I talked about World Vegetarian Day. Don’t know if it is the cold weather up here in New England or what, but I’ve actually been craving and cooking meat dishes. There was an incredible beef stroganoff on Halloween. Of course there was Thanksgiving turkey. There was more than enough breakfast bacon. And then, the January/February issue of Cook’s Illustrated arrived. If you don’t know about this amazing publication, they’re the folks associated with America’s Test Kitchen. While I cannot share the recipe, if you like beef stew, I’d encourage you to buy this issue (which also has a pulled pork recipe, whole wheat pasta comparisons, Thai chicken recipe, red beans and rice recipe). I have no affiliation with these folks, just can’t get enough of their incredible food science. At any rate, the beef stew was devoured. Bowls were licked clean. Bread was used to get every last drop of broth. The fact that a portion was shared with neighbors was cursed when there weren’t leftovers! Enjoy the photo essay:

EMRs in the Real World

I’ve been thinking a lot about EMRs (Electronic Medical Records) lately. Perhaps that’s because I’m interacting with an EMR for 10+ hours a day. Talk of EMRs is all over the news, discussed with health care reform, debated on blogs. A recent post on KevinMD also includes links to lots of other posts about EMRs. I’m no health information policy guru or medical economist, but I am a doctor who uses a comprehensive EMR and can see the pros and cons.

What do I like about the EMR?

• If you’re a patient within the system, all your records are in one place. If you see your PCP, see a dermatologist, have a colonoscopy, get prescribed an antibiotic, have your cholesterol checked or call with a question about flu shots, it’s all there.
• Medications are prescribed directly from the computer and faxed to the pharmacy. No more taking in a written prescription.
• Labs and imaging results come to my inbox like an email as soon as they’re done. Nothing sits in a pile of papers.
• *Can be accessed from home.

What do I dislike about the EMR?

• #1, by far, is that MY EMR does not talk to YOUR EMR. What I mean is that patients who have a PCP at medical group A, specialist at medical group B, get labs done at hospital C will have their records stuck in 3 different EMRs which do not talk to each other. Patients don’t understand that I can’t log into a hospital across town’s records from my office computer. We’re not connected. We still have to FAX a signed release to another hospital or medical group to get a printout of your electronic results FAXed back.
• A summary of a fully electronic office visit can look a little impersonal. I don’t think this will matter much to patients, but I miss the narrative of the HPI. It seems to get lost in a list of diagnoses and computer generated orders.
• *Can be accessed from home. Great when you need info when on call. Nice to finish up charting later. However, the 24/7 access can make it harder to truly disconnect.

The days of a thick paper chart with handwritten notes seems so antiquated. However, they did have one major advantage. About a year ago there was some type of computer catastrophe and the EMR was inaccessible for several hours. We didn’t know what to do! There are polices and procedures in place for computer failures, but it really was amazing how paralyzed we felt when that little glowing screen that guides our lives didn’t blink back!

Foodie Friday: Pittsburgh Salad

Earlier this week, I talked about cartilage research being done at the University of Pittsburgh. I’ve now been away from Pittsburgh longer than I lived there, but remember it as an amazing and beautiful city with so much to do. Two years was not enough. For those of you familiar with the ‘burgh, you will instantly know what I mean by Pittsburgh salad. How confused was I the first time I saw a tray of french fries sitting at the end of the salad bar? OF COURSE they are a salad topping! Not exclusive to salads, sandwiches from Primanti Bros have the fries right inside the bread/bun. Oh yeah! Don’t think I didn’t enjoy some of that!

This week, as a tribute to Pittsburgh, I made a salad with a few tweaks. I used sweet potato fries (which look like carrots in the photos) and couldn’t resist a few on the side with another Pittsburgh product: HEINZ ketchup! I also did a quick search to see what else I could find under the term “Pittsburgh salad” and found a new (to me) food blog with a similar recipe using rutabaga fries! Please excuse the cell phone pics: my camera went on a business trip this week!

Naked Salad

Pittsburgh Salad

Early Knee OA

Interesting article on early knee OA today in the New York Times’ Well Blog. During my fellowship at the University of Pittsburgh, I often heard about the research being done there on cartilage structure and function.

“Adopting” kids with cancer

Thankfully, it’s not often that I’m brought to tears at breakfast. However, I have to admit that the story about Friends of Jaclyn on “Only A Game” on NPR this weekend did just that. Give it a listen.

How a non-athlete exercises, part I

I am not an athlete.

Aside from about a 30 second stint at middle school intramural volleyball, I’ve never been on a team. Never had a coach. Never heard “there is no ‘I’ in team,” or “get out there and give it all you’ve got!” (Things I’ve heard coaches say in movies or TV). I don’t even really like to exercise, but as a physician I certainly understand the reasons for, and wish to achieve, at least a minimum of cardiovascular fitness. During the 80’s and 90’s, I managed to pretty regularly do aerobics tapes (yes, VHS TAPES) including Gilad and Cindy Crawford. In fact, I wore out Cindy’s Next Challenge Workout VHS tape and eventually bought it on DVD! During med school I found an old clothes rack NordicTrack in the classifieds (um, pre-ebay) and used that pretty regularly, usually watching taped (yes, VHS TAPES, again) episodes of ER trying to spot any errors. I also have taken my dogs on long walks (30-60 minutes) most days out of the week. Then, after the big 3-0, I really needed to start working on exercise with a purpose. That purpose was to counteract the weight gain from  too many nights on call with unlimited access to an excellent hospital cafeteria and fully stocked with junk food resident lounge.

I began the Couch-to-5K program and completed 2 5K races. I also took a Pilates class and a yoga class, both nothing fancy held in a school gym as part of the city parks and rec program. I tried a bean class. I tried one Zumba class (it was fun)! I tried one BodyPump class (it was hard)! Then I moved and began fellowship, moved again to join a practice, and the only thing I could really manage were the dog walks. Flash forward to 2 years ago, when my husband rediscovered his love of tennis, began playing in a league, and asked if I’d consider taking lessons. Quoting the movie Annie, “I’ve never even picked up a racquet!” I started taking a few lessons and eventually became good enough to hold my own playing in a clinic with others, though I am firmly stuck in the land of advanced beginner. I decided to go back to that couch-to-5K program and am now in week 6, and last night I had my FIRST EVER appointment with a trainer at the gym. Truth be told, I probably wouldn’t have signed up for it but it came free with a new gym membership, so I figured I couldn’t turn that down. It was hard. And humbling. And I realized, yet again, that I am not an athlete.

What have I learned about all these attempts at adult athleticism? Throw your pride out the window. Expect to be bad at it. Don’t let that bother you. Nobody is watching you. If they are watching you, who cares? If someone is insecure enough to make fun or laugh at someone else struggling, clearly that is his or her problem, not yours. Try to have fun with it. Don’t be afraid to ask for help. Something is usually going to be a little sore. Maybe a lot sore. You’re not going to be an expert. You will make progress. And you will be doing something good for yourself. So that’s my story, for now. I have more ideas, suggestions and links to come.

Foodie Friday: Failure?

After returning home from Thanksgiving weekend, I was in a bit of dessert withdrawal. Exhibit A: The holiday dessert table I snacked from for 2 days:

Many recipes were entertained for my post-holiday sweet craving. Should I make something healthy? I got all the ingredients for these truffles, but decided they were just too healthy. What about cutout decorated sugar cookies? I really wanted them, but so time-consuming for a random weekday. Finally I decided on the oatmeal scotchies recipe on the back of the Toll House bag, something I’ve made plenty of times before. However, the final product didn’t exactly turn out as expected. First, a photo essay:

Why did the cookies fall apart? Well, this was the inaugural use of some new flat cookie sheets.  I don’t know if that matters, but my husband pointed out that the new cookie sheets are much thinner than the old ones. When I put the cookies back in the over for 2 more minutes they held together better, but then developed a very dark, almost burned appearance, and barely rose at all. I’m used to soft, chewy oatmeal cookies and these were quite flat. The last batch I used an old cookie sheet with sides and they came out better, but still also flat and almost burned. I may need to adjust the temperature down a little if using the thinner cookie sheets? I also need to get an oven thermometer to calibrate the displayed oven temp.  The story has a happy ending, though. My co-workers almost inhaled the cookies I brought to work the next day and I heard, “Who made these awesome cookies?” down the hall. Maybe they didn’t look so great, but they tasted perfect. One of my co-workers even commented he liked these better than fluffier ones because they were a little chewier. Any comments and thoughts are welcome!

‘Tis the season of giving?

As the calendar page flips to December 1st and thoughts turn to holiday gift buying, I have been reflecting upon gifts to medical providers. During my medical school surgery rotation, which happened to be during December, I still recall the countertops piled high with cookie trays, nut tins, fruit baskets and flowers. Now, this was an office of a very loved and respected surgeon in the community, a man not too far from retirement, with seemingly endless thankful patients. I can’t say I’ve ever seen anything similar since then. However, likely all doctors will have stories about gifts they have received over the years. Primarily patients bring in handmade goods. I have received baked goods on many occasions, a hand-knit afghan, a dried flower wreath, candles and other similar items. It is always very touching and I’m honored when patients think of me and want to express appreciation. I recently was given a CD, which I’m pretty sure was from the patient’s own collection, weeks after he and I had a song lyric Q&A about some Sinatra. Of course, gifts are by no means expected and, truth be told, sometimes it is difficult to know how to respond. I did a little search to see if there are any formal guidelines about physicians accepting gifts from patients but I didn’t find anything on the Mass Med Society site about it. I did find this entry from the NYT Well blog, including the following quote:

As it turns out, the medical community is deep into a discussion about whether it’s appropriate to accept gifts from patients. Although small tokens like cookies or fruit baskets don’t usually pose a problem, physicians struggle with the ethics of accepting more costly or more personal gifts from patients. Doctors must maintain professional boundaries and don’t want patients to get the idea that gifts are necessary or that they might influence care. At the same time, doctors don’t want to insult or alienate patients by refusing gifts.

I’m curious: have you, as a patient, given a gift to a doctor or other medical provider? Do providers have any memorable gifts to share?

Meditation for Pain

The Stanford SCOPE blog recently had a few articles on chronic pain. Read them here and here.  The post on meditation for chronic pain links back to an LA Times article. One of the most frustrating and challenging conditions for patients and physicians alike is chronic pain.

I do speak with patients about mindfulness, meditation and yoga (which incorporates the first two) and often refer them to behavioral medicine chronic pain programs which teach these skills. Meditation is not a drug, supplement or procedure, it’s inexpensive and requires only an open mind. Resources for meditation include your public library, where there are often books on tape/CD and now many libraries have electronic downloads. My only advice is that when choosing guided audio meditation you may have to try a few styles. Nothing is worse than an irritating voice leading your meditation! Good luck and I hope to hear your mindfulness tips.