Dr. Ronan Kavanagh

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Rebooting the medical meeting – 9 lessons from TEDMED

In TEDMED, Uncategorized on April 13, 2012 at 9:57 am

A few things that medical meeting organisers could learn from the organisers of TEDMED.

1. Make presentations at TEDMED are 18 minutes long. This allows for large numbers of presentations with fine tuned ideas to presented in a polished digestible format to an audience.  George Bernard Shaw said. “I’m sorry this letter is so long, I didn’t have time to make it shorter.” Even the most excruciating presentation is bearable if you know it’ll be over shortly.

2. Give speakers guidance on their style of presentation with specific suggestions; e.g. “think big,  make the complex plain, connect with peoples’ emotions, don’t flaunt your ego, don’t read your talk, finish on time” etc. Check their slides well in advance of the talk and offer guidance. Speakers need to be guided and managed.

3. Introduce talks which stimulate thought, innovation and creativity rather than didactic hard data. It’s not always essential to have the answer or solution to make a presentation interesting.

4. Introduce an element to your meeting with speakers from disciplines outside medicine. At this TEDMED the innovative dynamic is generated by bringing together people from all sorts of disciplines passionate about healthcare; Some of the most exciting conversations / commentaries that took place this year at this years were with Architects, Climate Change specialists, Neurobiologists, Experts in Social Networks, Plant Biologists, Technology Entrepreneurs, Gamers, Military personnel, Poets, Musicians and dancers.

5. Broadcast to remote locations so people don’t have to attend. TEDMEDlive broadcast to 100’s of institutions around the US this year allowing exposure of a much larger number of delegates to presentations. Certain delegates will need to attend for a more immersive networking experience but many delegates could gather in groups around the world creating smaller, more intimate and manageable communities to allow meaningful local discussion.

6. Introduce Social Media to the event to allow two way discussions between delegates (those present and remote) and speakers. This could be by using Twitter  but the use of a mobile App for registered delegates would allow questions to be collated and filtered by the chairperson for the session. Put an end to the usual suspects hogging the mike from the floor. This also means that organisers will need to use high quality free Wifi and recharging facilities for mobile phones and laptops.

7.Using crowd sourcing to ask the questions that physicians most want the answers to – those questions could then be answered by experts based on data gleened from novel research presented at those meetings. These questions could also be used to prompt areas of research deemed to be relevant by the broader medical community. A novel tool presented at this years meeting by management consulting firm Booz Allen Hamilton allows crowdsourcing of ideas at a conference allowing the most popular sugestions to percolate to the top of the list.

8. The most moving, insightful and powerful presentations at this years TEDMED meeting were presented by patients (some of whom were physicians) or by their carers. The patient perspective introduces an essential element and the ultimate stakeholder in to the conversation. The power of the patient narrative should not be underestimated and reintroducing some humanity into a tsunami of medical data reminds us why we’re here.

9. Introduce an element of fun into the meeting. Make people laugh, make them angry or make them cry. The impact of a creative element from the Arts in the programming (apart from presenting a pleasing distraction to complex medical data) contributions from poets / artists /comedians may allow us to create fresh perspectives and imaginative leaps. We need to be inspired by people who are real risk takers.

What do you think?


The Future of Health and Medicine is Here

In TEDMED, Uncategorized, Wireless Medicine on April 11, 2012 at 9:44 am

I’m at at the JFK centre in Washington this week to attend a meeting with big ambitions for healthcare. TEDMED is a meeting which celebrates (not a word often used in the context of healthcare meetings, trust me) the imagination, innovation and inspiration that occurs at the intersection of science, technology, government, business, art and education.

Yesterdays’ opening session showcased no less than 4 different performances from the arts community who showed us things (through dance, song writing, wordplay, humour and extraordinary feats of imagination) that we would have never thought possible. Although I have always had an awareness that arts had something to offer healthcare, I had never before this considered that the Arts might have the potential to help doctors and health care providers think differently – to inspire us to take big imaginative leaps of faith or to inspire us to think about things which we thought weren’t possible. The idea that a cardiology, oncology or rheumatology meeting would be opened by a group of acrobats on skateboards might seem ridiculous to those not attending TEDMED but I’m beginning to see its charm.

I had quietly assumed that the opening sessions might place an emphasis on some new great feat of technology. Two of the opening presentations made strong arguments on how the most important elements of change that need to take place in healthcare have nothing to do with technology at all. Bryan Stevenson, a public interest lawyer spoke about harnessing the power of identity in shaping peoples’ expectations of themselves, and how recognising our essential humanity should be at the core of any intervention. Rebecca Onie social entrepreneur and co-founder of Health Leads reminded us how the most important interventions in health don’t even need to involve any clinical input. Those of us caught up in the frenzy of the untold promises of the technological revolution in medicine need to take stock.

‘In attempting to follow the narrative of man’s ambitious progress towards a state of technological and political perfection, we have sacrificed opportunities to remind ourselves of the quieter truths which we know about in theory and forget to live by in practice’ – Alain de Boton

#rheumedu. A new Hashtag for Rheumatology education

In Uncategorized on March 24, 2012 at 1:08 pm

Rheumatology healthcare professionals need a Twitter Hashtag to assist in the education of specialists through the the exchange of clinical and practical information relevant to rheumatology.

It is my intention that the Hashtag, #rheumedu will be used predominantly by healthcare professionals involved in the care of patients with musculoskeletal problems (but of course anyone who is genuinely interested is welcome to post or comment).

Whereas there are a number of useful disease specific hashtags being used by healthcare professionals and patients alike, I feel rheumatologists need a forum with a focus on the exchange of information relating to the practice of our specialty. This will involve the sharing of clinically relevant papers, educational resources, clinical anecdotes, practice management tips or physician requests for information from their colleagues.

I deliberately haven’t limited chats to a specific time. Feel free to post at any time of the day or night.

I would be really grateful if all rheumatologists or other healthcare professionals involved in the rheumatic disease would consider using the hashtag when posting information that they feel will be of interest to their peers.

Thanks to Andrew Spong for the name suggestion.

Methotrexate and Rheumatic Diseases. A video blog.

In Arthritis and Rheumatism, rheumatoid arthritis, rheumatology, Uncategorized on February 17, 2012 at 8:27 pm

This is a brief video I have prepared which may be of use to patients who have rheumatoid arthritis or psoriatic arthritis (or other arthritis illnesses) considering taking Methotrexate as an arthritis treatment.

It outlines some of the important side effects of methotrexate but also puts them in perspective based on my many years using the drug as a rheumatologist.

This is my first attempt at providing medical information using youtube.

I’d be interested in what people genuinely think of the information posted.

Is it too detailed?

Isn’t it detailed enough?

Are there other topics you’d like to see covered? Please let me know.

Internet usage in Irish Medical patients – A survey

In Uncategorized on January 19, 2012 at 5:21 pm

As we are on the verge of moving over to an online appointment booking system and extending the use of texting to patients in our practice, we recently undertook a  survey of our patients. Over the last week, patients in our practice have been patiently completing questionnaires regarding their use of mobile phones, texting and internet usage. Thanks to all of those who took the time to do the survey.

These results apply to a special and limited section of the population and may not be applicable outside of the setting of a private rheumatology outpatient clinic and should be interpreted in this light.

We surveyed all patients presenting to the outpatient clinic of two rheumatologists (Dr. Adrian Gibbs and Dr. Ronan Kavanagh) over a one week period. 124 patients completed the survey.

The patients surveyed are that bit older than the general population (Median 57 yrs vs 34.8% nationally), more likely to be female (2/3 are women vs 50% in the general population) a bit more affluent than average (there is some data to suggest that internet usage is higher in those with higher incomes).

Even allowing for the fact that our patient population is higher than that in the general population, the results of this survey show that mobile phone, texting and internet usage is high amongst patients attending our clinic.

Here’s a summary of the results.

  • 96% of our patients have a mobile phone
  • 84% are able to send and receive text messages
  • 72% of our patients have internet access
  • 70% of our patients who do not have internet access indicated that they a family member who accessed it on their behalf
  • 41% of our patients are on Facebook and 18% on Linkedin and only 5.3% have Twitter accounts
  • 83% of our patients send or receive emails daily or a few times a week
  • 79% have researched a product or service online
  • 83% have looked online for information about a specific disease
  • 70% have looked online for information about medical treatment or procedure.
  • 59% have looked online for information regarding health insurance
  • 56% of those with a Facebook account post updates daily or a few times a week and 44% post rarely of never post.
  • 88% of those who had visited the Arthritis Ireland Website indicated that they thought it was either good or excellent
  • None of our patients have ever posted an online review of a doctor and only 2.5% have posted a review of a hospital online.

The majority of our patients have a mobile phone. Whereas 84% of patients indicated that they are able to receive AND send messages, it is possible that had we asked the question in two parts, there would have been greater percentage of patients who knew how to receive / read text messages.

The internet usage in our patients is very similar to that in the general population. 72% of our patients use the internet and 69% of Irish households have internet access. Only 41% of patients who use the internet indicated that they have a Facebook account compared with the 69% of Irish internet users (or 45.3% of the Irish population). This probably reflects the older average age of our patients. Also of those who have a Facebook account 25% rarely post and 20% never post messages (figures are similar for Linkedin users with 51% posting daily or a few times a week).

Many of our patients have researched a product or service online and most have looked online for information about a specific disease,treatment or procedure but very few patients have looked at doctor or hospital ratings websites and none of them have rated their doctor in an online ratings site.  Irish internet users, it would seem, are internet ‘Lurkers’ and like to watch rather than post updates or comments.

Overall, the results of this survey suggest a high proportion of our patients will be in a position to avail of an online booking system when put in place. Whereas we have had a text reminder service for all outpatient appointments for the last few years, until now we did not know what percentage of our patients might be able to avail of it. We are now going to extend this to annual recall appointments and where possible send  dual reminders by text and email.

Summary graphs appear below

The Weather, Arthritis and Woody Allen’s Orgasmatron.

In Arthritis and Rheumatism, Osteoarthritis, rheumatoid arthritis, Uncategorized, Weather on January 9, 2012 at 4:36 pm

Woody Allen’s 1970 movie ‘Sleeper’ introduced its audience to a fictional, futuristic device called the Orgasmatron. This remarkeable invention was capable of inducing physiological changes (of a pleasurable kind) in those placed within it. I sometimes wonder how much Woody Allen’s contraption was influenced by a device with a similar name from the early 1960’s in which the earliest scientific experiments on the effects of weather on arthritis symptoms were performed.

The Orgasmatron in action

The Climatron, as it was referred to in media reports of the time, was used by Professor Joseph Hollander, a Philadelphia based rheumatologist to determine the effects of the weather elements on the symptoms of arthritis patients. The device was basically a hotel room sized chamber (with room service) which was designed to comfortably house two patients for periods of two to four weeks. Using a system of valves and dials, it was possible to adjust the temperature, humidity, rate of air flow, barometric pressure within the chamber.

The Climatron in action (with Prof Hollander)

In his experiments, a small group of largely ‘weather sensitive’ arthritis patients, were recruited to come and stay in the Climatron. A number of times a day they completed a diary documenting various aspects of their health including assessments relating to their joint symptoms. They were also examined by a doctor and had their joints assessed. None of the subjects were aware that the main focus of the research was their joint symptoms and were not informed about changes being made to the weather variables within the chamber.

When individual weather variables were adjusted in the Climatron, none of the subjects  noted any difference in their joint symptoms. However when an attempt to reproduce the weather conditions of imminent stormy weather (simultaneous increase of humidity and reduction in atmospheric pressure) the effect on symptom worsening was significant in 7/8 of the rheumatoid patients and in 4/4 of the osteoarthritis patients. When this experiment was completed a number of times, those who noted a worsening did so about 3/4 of the time.

This was one of the first scientific attempts to correlate arthritis symptoms and the weather. Whereas the results are tantalizing, its hard, in view of the small numbers of patients studied, to draw any firm conclusions.

Arguments for there being a link

The strongest suggestion that arthritis symptoms are affected by weather is from patient surveys. About 2/3 patients in some studies state that their pain is worsened by certain weather changes. Some report how their joints help them predict the imminent arrival of wet weather, some note a dramatic improvement in their pain while on holidays in the sun (only to deteriorate on their arrival home ) and some even notice a worsening of their symptoms during heat waves. Whereas surveys are interesting, they don’t necessarily prove the link.

However, there are also some semi-plausable mechanisms as to how weather might affect joint symptoms; We know that joints  contain pressure receptors (baro-receptors) for example. Couldn’t changes in atmospheric pressure therefore be detected within joints ? The problem is that the sorts of barometric pressure changes seen with weather fluctuations are small and only of the sort of magnitude that might be experienced going up and down in a lift or on an airplane journey. It is also true that the physical properties of  tendons and cartilage can be altered by temperature changes but again, this has only been shown in laboratory experiments using extremes of temperature not usually seen in the environment . There’s even some evidence that levels of inflammatory proteins (cytokines) have been shown to decrease in patients undergoing hot spa therapy with inflammatory arthritis and of course heat (or cold) applied directly to joints also seems to help some patients too.

Some patients feel can predict weather changes in their joints

What’s surprising therefore is how prospective scientific studies over the years have failed to show a consistent relationship between various weather variables and arthritis symptoms.

This is at least partly due to the fact that these studies are difficult to do. If the weather were a new drug and researchers were trying to determine its effectiveness in the treatment of arthritis, we would be obliged to ‘blind’ both the patients AND their assessors to their weather treatment (a wet day, dry day etc). Its hard to be ‘blind’ to the weather. Unless you spend all of your time indoors – but then you are not being exposed to the weather changes (other than barometric pressure) either. People also wear clothes most of the time, which alter the humidity and temperature around joints and which could ‘blunt’ any effect that external factors might have.

Other investigators point to the difficult confounding role of psychological factors. Where someone with arthritis holds a belief, for example, that damp cold weather worsens their symptoms, they are psychologically more likely to place emphasis on information that reinforces this idea. They might be more likely therefore to remember those days where their joints were bad AND where the weather was damp and cold but not place emphasis on days where the weather was damp and cold and their joints were good. It has also been suggested that bad weather causes patients to feel depressed or to become inactive – both factors which have been shown to worsen pain.

What’s the bottom line:

Although the data is confusing, I tend to believe my patients when they tell me there joints are effected by the weather. This is true for some patients but not for all.

In my opinion, and despite and firm to data to back it up, I believe the following;

1. That arthritis is not caused by cold or damp weather. There is no evidence whatsoever that this is the case.

2. Where weather has an effect on arthritis,  it is solely on the symptoms of the disease and has no effect on disease progression or structural damage.

3. The effect of weather on arthritis symptoms varies from patient; as a rule I would have said that most patients prefer dry warm weather to cold damp weather. Patients with poorly controlled rheumatoid arthritis can occasionally flare when its very hot.

4. The better controlled a patients disease, the less they will notice fluctuations with weather changes. This is particularly true of patients with inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis).

5. Emigrating for a better life with your arthritis is probably not a good idea. If an improvement is noted on moving to another country it is quite often temporary. Uprooting yourself from the support network of your family and friends isn’t a good idea and then there’s the stress of moving to another culture, negotiating another health system etc.

6. As with all things that you can’t control its probably better not to stress about it too much. You can’t control the weather…

Sun going down on Galway bay.

Emigration and arthritis. Some things to consider.

In Arthritis and Rheumatism, rheumatoid arthritis, rheumatology, Uncategorized on January 4, 2012 at 6:50 am

One of the realities of Ireland’s fall from economic grace is the large numbers of people emigrating from our shores in search of a better life.

I know this because amongst them are some of my younger patients in my practice, many of whom are afflicted with conditions like rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Whereas many of them are doing well on treatment, and seem quite up-beat and excited to be considering the idea of a few years away, there are some downsides to consider. This is particularly true for those who are on biologic treatments for their arthritis.

Biologic therapies are a group of modern, hi tech and effective treatments for certain types of arthritis. They are also very expensive. The annual cost in this country for a patient treated with once of these drugs ranges from €15,000 to €20,000.

Although many gripe about the state of the Irish health service, one of the things it does very well is provide funding for these drugs. At present (although likely to change) there are very few restrictions on a Irish rheumatologist’s ability to prescribe biologic therapies for arthritis.

Every Irish citizen is entitled to have the costs of  subcutaneous biologics (e.g. Enbrel, humira, Simponi, Cimzia) covered (subject to shortfall)  through a fund known as the ‘HiTech scheme’.  This is usually subject to maximum shortfall per family of €132 per month and about a third of the Irish population who have a medical card (those over the age of 70yrs and those below a certain income) which entitles them to (almost) free medical care where they have to pay 50c per month per item on their prescription. The centrally funded Hi Tech scheme (which is ring fenced from other health service costs),  does not cover the costs of the Intravenous biologic drugs (e.g. Remicade, Roactemra and Orencia). These are usually funded through local hospital budget (much to the chagrin of public hospital administrators). Those with private health insurance have the costs of intravenous drugs and related infusion costs met by their insurer (a bit less than 50% of the Irish population carry health insurance).

For those patients who are considering changing jurisdiction  there are always two considerations when it comes to getting continued access to your regular arthritis medication.

1. The first is that a change in country means a change in rheumatologist. Where your new rheumatologist will effectively be the gate keeper to access treatments, your ability to get access to these drugs depends wholly on your new rheumatologist agreeing that biologic therapy is appropriate for you. Whereas consensus for patients with more severe forms of arthritis is unlikely to differ, there are often grey areas where opinions may vary. The decision making process however is more likely to be informed by local funding issues.

2.Funding for biologic therapies is much more restricted in other countries. For example, in Australia, access to biologic therapies for anklosing spondylitis is restricted to patients with a certain grade of severity of AS on Xray whereas in Ireland it is wholly at the discretion of the treating rheumatologist.

3. Even where you have Irish private health insurance, it will usually only cover you for emergency treatment abroad for a certain period.

What is the best advice for those thinking about emigrating who are on treatment?

1. Be aware that you may not automatically entitled to access to biologic treatments abroad. The HiTech scheme in Ireland only covers the cost of drugs of patients living here.

2. If you are thinking about emigrating, discuss it with your rheumatologist before making any firm decision. He/She may be able to recommend a rheumatologist and initiate contact for you.

3. Firmly establish the funding guidelines and restrictions on prescribing of these drugs in your target country and ask your rheumatologist for advice. I have included links to the UK (NICE) guidelines (for Rheumatoid arthritis Ankylosing Spondylitis Psoriatic arthritis , Australian Medicare guidelines (Rheumatoid arthritis , Ankylosing Spondylitis, Psoriatic arthritis) and Canadian guidelines. US regulations are much more complicated. I think it would be fair to say that having health insurance in the US would be imperative and that you would need to establish from the target insurer what their coverage guidelines are. Get it in writing!

If you are a patient in a country other than Ireland who has guidance you’d like to offer to foreign patients thinking of emigrating you your country, please add a comment.

Arthritis with normal blood tests? Why not..

In Arthritis and Rheumatism, Dr. Ronan Kavanagh, Osteoarthritis, rheumatoid arthritis, rheumatology, Uncategorized on December 20, 2011 at 7:04 am

To most medical students and patients uninitiated in the science of rheumatology, the diagnostic process whereby rheumatologists assess patients may seem bewildering. When considering any patient who presents with joint pain, there are over 100 types of arthritis to consider, lots of conditions which mimic arthritis, a huge array of blood tests to consider and any amount of expensive imaging tests at our disposal. Sounds complicated? It’s not as hard as it seems. When you take gout and joint infections out of the mix (usually easy to spot if you know what you’re doing), you are really trying to determine if your patient has one of two categories of joint problem; a problem relating to joint degeneration or one relating to inflammation.

Only two types of arthritis to consider. That shouldn’t be too hard to do now should it? Here’s some of blood tests that help us do it;

Inflammation blood tests (ESR, CRP)

The results from these two readily available and relatively inexpensive blood tests are probably the first tests any rheumatologist looks for on a patient are the ESR (‘sed rate’) and CRP. These two complementary blood tests help us differentiate between patients with active inflammatory arthritis (eg rheumatoid, psoriatic, reactive arthritis, undifferentiated inflammatory arthritis, ankylosing spondylitis) and those with degenerative joint problem or with other causes of their pain. Although they can be become elevated in conditions other than arthritis (infections and malignancies for example) I tend look on them as measuring the ‘temperature’ of any inflammatory process. The higher above the normal range they are, the more intense the inflammation present. In certain disease states (eg rheumatoid arthritis), very high levels can help us identify patients at higher risk of damage. The closer to the normal range they are, the less likely a patient it to have an inflammatory process. These tests are also used to help monitor the activity of inflammatory arthritis and its response to treatment (one of the ways we know treatment is working is that the CRP / ESR falls during treatment) These tests are not infallible by any means. For a list of pitfalls in their use see below under specific conditions.

Disease Markers (RF, CCP, ANF/ANA)

Once a doctor suspects a patient has inflammatory arthritis, these disease specific tests are used to determine which type of inflammatory arthritis (or other connective tissue disease) they have. Examples of these tests would be Rheumatoid Factor (RF), CCP antibody and Anti Nuclear antibodies (ANA/ANF).

The majority of rheumatoid arthritis will have a positive rheumatoid factor test (‘seropositive’) or a positive CCP antibody (CCP positive). Rheumatoid factors can also occur in some other conditions (eg SLE, Sjogren’s syndrome) but CCP antibodies are usually only present in patients with rheumatoid arthritis. The presence either of these antibodies can help identify patients who are at greater risk of more severe forms of rheumatoid.

There is also some evidence that these antibodies can be present for many years in people before they develop rheumatoid arthritis so be positive in patients without symptoms. The ANF* is usually positive in SLE but can be positive in patients with rheumatoid arthritis. Confused yet?

*Further discussion of the use of Antinuclear antibodies is beyond the scope of this piece

Osteoarthritis

This is the commonest form or arthritis and a condition where ALL of these blood tests listed above should be normal. That means normal ESR, CRP, RF and CCP antibodies unless there’s another condition present alongside the osteoarthritis.

Rheumatoid arthritis

The ESR or CRP may also be normal in patients newly presenting with rheumatoid arthritis. In a large study of RA patients from Finland and US, between 45-47% of patients had a normal ESR, 44-58% had normal CRP at presentation. BOTH were normal in 33% and 42% of patients**. When a rheumatoid factor test was included, 14-15% of patients had no abnormalities in all 3 tests.

Remember that only 70-80% of patients will have a positive rheumatoid factor or CCP antibody (and one can be positive whether the other is negative so we tend to do both) and even greater percentages of pts will have negative antibodies (‘seronegative arthritis’) early on. Having negative antibodies does not therefore exclude rheumatoid arthritis.

It is also well describedthat inflammation can be visible in the joints using MRI ultrasound scans in patients with known rheumatoid arthritis in the absence of inflammation clinically or on blood tests.

** the reason there’s two percentages mentioned is that they looked a patients in two different countries (Finland and USA)

Psoriatic arthritis

Many patients with psoriatic arthritis (approximtely 50%) will have either normal or near normal ESR and or CRP levels. Patients with Psoriatic arthritis will usually have negative rheumatoid factors and CCP antibodies and Antinuclear factors.

Ankylosing Spondylitis / Undifferentiated spondyloarthritis

Ankylosing Spondylitis is a form of inflammatory arthritis (largely affecting the spine). Whereas abnormal CRP and ESR can be very helpful in making a diagnosis of AS in certain patients with back pain, these tests will only be abnormal in about 50% of patients. The rheumatoid factor, CCP antibodies and ANA should be negative in this group of patients.

Palindromic Rheumatism

Palindromic Rheumatism describes a syndrome where there are recurrent episodes of pain swelling warmth and stiffness of joints. The symptoms can have onset over hours and last days – weeks, before subsiding. However episodes of recurrence form a pattern, with symptom free periods between attacks lasting for weeks to months and some of these patients will go on to develop rheumatoid arthritis. It is not unusual for these patients to have normal inflammatory indices (especially between attacks, when they are well) and approximately 50%will have negative Rheumatoid factor and CCP antibodies.]

Conclusions

Making a diagnosis of inflammatory arthritis in patients is usually straightforward but there are some pitfalls to catch the unwary. Whereas the tests can be unreliable in some settings, with the right history and clinical examination in the hands of an experienced rheumatologist, it is possible to make a diagnosis of inflammatory arthritis and offer effective treatment even where the labs don’t quite fit the picture.

My list of rheumatologists who blog

In Arthritis and Rheumatism, rheumatoid arthritis, rheumatology, Uncategorized on December 5, 2011 at 1:40 pm

I have collated this list of rheumatologists who blog regularly from around the world. Please let me know in the comments section if I’ve missed anyone and I’ll add them. Apologies to you if you’re one of them.

A typical blogging rheumatologist

I’m on the list too but then you know that because you’re on my blog reading this…..

http://bjcconnectedcare.com/ by Dr. Irwin Lim, Sydney, Australia
http://rheumatologe.blogspot.com/ by Dr. Lothar M. Kirsch, Meerbusch,
Germany
http://www.arthritissupportboard.com by Dr. Shashank Akerkar, Mumbai
India
http://www.carvica1.blogspot.com/ by Dr. Carlo V Caballero,
Barranquilla, Colombia
http://paulsufka.com/ by Dr. Paul Sufka, Minnesota, USA.

The Doctors’ Rheum by Dr. Julie Levengood Worcester, MA, USA
http://blogs.medscape.com/brunooliveira by Dr. Bruno Oliveira,
Billings, Montana, USA

http://larhumato.com/ by Dr. Francis Berenbaum, Paris, France

The sexiness of rheumatology.

In Arthritis and Rheumatism, Dr. Ronan Kavanagh, rheumatoid arthritis, rheumatology, Uncategorized on October 30, 2011 at 1:10 pm

Although as a medical student rheumatology was always associated with an air of mystery and complexity to me  – factors which might have aroused a younger me had they been associated with a member of the opposite sex –  the specialty didn’t catch my eye at all as an undergraduate. To a medical student cruising for medical action in the 1980’s, rheumatology wouldn’t have got as far as a first date.

Some medical specialties are cooler and sexier than others. Rheumatology could never really compete with the macho surgical cool of heading down to theatre to sew a hand back on, performing open heart sugery or with the laid back anaesthetic cool of medically paralyzing someone, stopping their heart and lungs and then starting them up all over again (while reading the paper). Rheumatologists just didn’t wear leather jackets.
At that time, and despite its best efforts, my chosen specialty had an image problem.This wasn’t the fault of the rheumatologists; we just didn’t yet have the effective tools at our disposal to significantly impact on many of the disease we treated. Nonetheless this affected the attractiveness of our specialty to those choosing a career in hospital medicine and to our colleagues in other specialties. Rheumatologists were seen by their colleagues as a specialists who provided a babysitting service, albeit with lots of steroids, to the chronically unwell. Our clinics were full of struggling patients for whom the treatments didn’t work and there were even special clinics to deal with side effects to the drugs we were prescribing (‘Gold clinics’ were not as glamourous as they sound).
With my heart set on a career in the rapidly evolving, hi-tech and terrifically sexy specialty of radiology, I decided to get some general medicine under my belt before going for the interviews. Accidentally stumbling into a few months of rheumatology as part of one of the jobs, I surprised myself by beginning to like the job. If I’m honest, the first thing I liked about it was that it seemed like a bit of a doss. In my first few weeks that summer I found myself regularly clipping my on-call bleep to the net of the hospital tennis courts to hit a few balls with another member of the team waiting for  ‘something to happen’. Although it was a false dawn (the job became much busier in the following weeks), I allowed myself to imagine a a job which allowed a life outside medicine.
I liked the rheumatologists too. Most seemed to be very down to earth and have a genuine interest in the lives of the people they cared for. It seemed to be a specialty there was at least some stuff could wait ’til the morning. This allowed a measured commitment to the workplace in those I worked with that seemed to leave room for time with family, friends and for non-medical interests. Although rheumatology is not as well paid as some other specialties, I resigned myself to the certainty that if were to become a rheumatologist that I’d never own a Porsche. But then neither would I have to drive it into A+E in the middle of the night to unblock someones coronary arteries.
Rheumatologists also seemed to have a level of familiarity with their patients that I might have imagined an older rural family doctor might have, effortlessly blending the catch up familiarity of a chat between old friends with the medical business of dose adjustments, joint injections and referrals to orthopaedics. Whereas I now know that this approach and those relationships can take many years to develop, it liked its feel.
I liked the mix of clinical problems coming along to the clinic; in a single morning you could see a patients with tennis elbow, rheumatoid arthritis, gout, osteoporosis, osteoarthritis, vasculitis, lupus and even a few of the worried well. There was a nice mix of clinical medicine (where most of the clues are there from listening and examining), a bit of hi-tech imaging (with MRI, Nuclear Medicine) and a bit of nerdy hardcore science and immunology thrown in. Most of all though, I liked the patients.
Rheumatology patients are an amazingly resilient, patient and forgiving group of people. They are often cheerfully resilient while coping with the ravages and disappointments of living with a chronic disease, patient in their wait for slow acting treatments to work (and where our clinics run behind!). They forgive rheumatologists when initial attempts to treat their disease fail (we’ve got to sometimes chop and change til we get the right cocktail for every patient) but always express gratitude when things go well.
Thankfully rheumatology is entering a new era. The vast majority of patients with rheumatoid arthritis will do very well on treatment. The impact that modern treatments have had on joint damage means that for most patients, joint deformities are rare of and as result referrals to orthopedics and plastic surgery have dropped. Outcomes from sometimes fatal connective tissue disease like vasculitis and lupus have improved dramatically and we are now very good at treating gout, osteoporosis and getting better with chronic pain management.
Although I always thought that rheumatologists had reason to feel good about their role in the lives of their patients and their place in medicine, I think it is about time we added a little swagger to our ward rounds. I think I might just pop out and buy myself a leather jacket…..
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