Larry Greenbaum, MD

When I went into practice in 1989, patients used to comment about my youthful appearance. "I thought the arthritis doctor had to be old," they told me. The years rolled by, and those comments became much less frequent. Nowadays, patients are more likely to ask me if I have arthritis, rather than comment on my youthful appearance.

Sometimes patients come back to the office after a hiatus of several years and compliment me that I have not aged in the interval. One bit of blarney deserves another, so I deflect the compliment by telling them I’m well preserved, because my patients are so nice to me. One lady became sentimental and insisted that she had been seeing me for 30 years, and I had to disabuse her of this fantasy by reminding her that I have only been at my current practice for 19 years, although it feels like I’ve been here forever.

No matter how much I love my work, I have to face the fact that one day I won’t be able to inject creaky knees or mash on fibromyalgia tender points. All good things come to an end, and I’ll have to face the frightening specter of retirement. Although I feel great, my heart tells me that I am approaching old age. If I had my choice, I would tarry in middle age forever, but that isn’t one of the options on the multiple-choice test of life.

Petite reminders of my rusty vintage pop up all the time. Just the other day, a family practice resident with whom I was seeing patients, let out a small exclamation of horrified surprise when I pulled my beloved Palm Pilot out of my pocket. I use it for reminders as well as the handy epocrates program. The resident remarked, "I had one of those when I was a medical student," with the tone of voice of someone recalling some distant epoch. I’m the last holdout on the planet without a smartphone, and I could tell from his slightly shocked demeanor that I looked completely "retro" sporting a gadget more suitable for the last millennium. I might just as well have pulled a slide rule out of my pocket.

I’m aging, but I have plenty of company for the journey. One of my colleagues is a silver-haired neurologist. Anytime one of my patients has an EMG, and tells me the doctor was old, I know exactly who they mean. He’s a sharp cookie, but younger patients are suspicious that older doctors are out of touch with cutting-edge medicine. That attitude bothers me more these days, and I know it is only a matter of time before my younger patients view me with the same prejudice. Put yourself in the place of a younger patient visiting a senior doctor. You ask a question, and the doctor consults a Palm Pilot instead of an iPhone. Does that shake your level of trust in the old codger’s answer?

Are senescence and retirement inevitable features of old age? Does chronology rule my destiny? My patients have taught me many valuable lessons, but perhaps I wasn’t paying attention when they taught me the "indications" for retirement. I often remind patients that they need to do something meaningful after they retire. Many of my retired patients are quite content with their hobbies or tending to their grandchildren. Parenthetically, when I see patients who are new to the neighborhood, I can usually guess their motivation for moving. Young people move here for jobs, and older people move here to be closer to their grandchildren. Grandchildren are the tail that wags the dog for seniors.

A retired factory worker who gets bored sitting at home can take a part-time job driving a truck, or work as a greeter at Walmart, but that won’t cut it for a physician. It’s much harder for a doctor to come to grips with the end of a career than it is for other professionals. A thousand daily seductions beguile us into believing we are indispensable, but how can our lives remain meaningful, if our patients no longer need us? During our careers, patients clamor to see us, and they are petulant when we are not available. Smartly dressed drug reps line our hallways and wait patiently for a minute or two of our time. Like it or not, all of this attention goes to our heads. We may strive to act humbly, but we understand that we are very important in the lives of many people. We use our skills to heal, and that gratification, which is unique to the medical profession, is very addictive. I realize that the world will not stop turning if I am not there to refill prescriptions and give technical support for the human body, but how do doctors bow out gracefully?

For some doctors, retirement is a punishment, like solitary confinement. I remember one orthopedist who retired early, while I was knee deep with things to do at the office. Later I heard through the grapevine that he died young from cancer, so that curbed any feelings of jealousy I may have harbored. I’m not suggesting that if he had continued to work he could have dodged the bullet, but I’m suspicious that the secret of youth is acting the role. In my mind’s eye I picture the fearful spectacle of my retirement party. Other professionals get a golden watch for a retirement gift. A golden goniometer is more appropriate for a rheumatologist, but I’m deathly afraid to accept it. Don’t grab the scepter of purpose and meaning from my doddering old hands a minute sooner than you need to!

Another colleague is retiring to Arizona after many years of family practice. He’s planning on working 3 days a week in a friend’s practice. I think his concept of retirement is much healthier, and I wish him well. The way I see it, work is like prednisone: You have to taper off very slowly, and sometimes you have to stay on a little bit forever.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

When I went into practice in 1989, patients used to comment about my youthful appearance. "I thought the arthritis doctor had to be old," they told me. The years rolled by, and those comments became much less frequent. Nowadays, patients are more likely to ask me if I have arthritis, rather than comment on my youthful appearance.

Sometimes patients come back to the office after a hiatus of several years and compliment me that I have not aged in the interval. One bit of blarney deserves another, so I deflect the compliment by telling them I’m well preserved, because my patients are so nice to me. One lady became sentimental and insisted that she had been seeing me for 30 years, and I had to disabuse her of this fantasy by reminding her that I have only been at my current practice for 19 years, although it feels like I’ve been here forever.

No matter how much I love my work, I have to face the fact that one day I won’t be able to inject creaky knees or mash on fibromyalgia tender points. All good things come to an end, and I’ll have to face the frightening specter of retirement. Although I feel great, my heart tells me that I am approaching old age. If I had my choice, I would tarry in middle age forever, but that isn’t one of the options on the multiple-choice test of life.

Petite reminders of my rusty vintage pop up all the time. Just the other day, a family practice resident with whom I was seeing patients, let out a small exclamation of horrified surprise when I pulled my beloved Palm Pilot out of my pocket. I use it for reminders as well as the handy epocrates program. The resident remarked, "I had one of those when I was a medical student," with the tone of voice of someone recalling some distant epoch. I’m the last holdout on the planet without a smartphone, and I could tell from his slightly shocked demeanor that I looked completely "retro" sporting a gadget more suitable for the last millennium. I might just as well have pulled a slide rule out of my pocket.

I’m aging, but I have plenty of company for the journey. One of my colleagues is a silver-haired neurologist. Anytime one of my patients has an EMG, and tells me the doctor was old, I know exactly who they mean. He’s a sharp cookie, but younger patients are suspicious that older doctors are out of touch with cutting-edge medicine. That attitude bothers me more these days, and I know it is only a matter of time before my younger patients view me with the same prejudice. Put yourself in the place of a younger patient visiting a senior doctor. You ask a question, and the doctor consults a Palm Pilot instead of an iPhone. Does that shake your level of trust in the old codger’s answer?

Are senescence and retirement inevitable features of old age? Does chronology rule my destiny? My patients have taught me many valuable lessons, but perhaps I wasn’t paying attention when they taught me the "indications" for retirement. I often remind patients that they need to do something meaningful after they retire. Many of my retired patients are quite content with their hobbies or tending to their grandchildren. Parenthetically, when I see patients who are new to the neighborhood, I can usually guess their motivation for moving. Young people move here for jobs, and older people move here to be closer to their grandchildren. Grandchildren are the tail that wags the dog for seniors.

A retired factory worker who gets bored sitting at home can take a part-time job driving a truck, or work as a greeter at Walmart, but that won’t cut it for a physician. It’s much harder for a doctor to come to grips with the end of a career than it is for other professionals. A thousand daily seductions beguile us into believing we are indispensable, but how can our lives remain meaningful, if our patients no longer need us? During our careers, patients clamor to see us, and they are petulant when we are not available. Smartly dressed drug reps line our hallways and wait patiently for a minute or two of our time. Like it or not, all of this attention goes to our heads. We may strive to act humbly, but we understand that we are very important in the lives of many people. We use our skills to heal, and that gratification, which is unique to the medical profession, is very addictive. I realize that the world will not stop turning if I am not there to refill prescriptions and give technical support for the human body, but how do doctors bow out gracefully?

For some doctors, retirement is a punishment, like solitary confinement. I remember one orthopedist who retired early, while I was knee deep with things to do at the office. Later I heard through the grapevine that he died young from cancer, so that curbed any feelings of jealousy I may have harbored. I’m not suggesting that if he had continued to work he could have dodged the bullet, but I’m suspicious that the secret of youth is acting the role. In my mind’s eye I picture the fearful spectacle of my retirement party. Other professionals get a golden watch for a retirement gift. A golden goniometer is more appropriate for a rheumatologist, but I’m deathly afraid to accept it. Don’t grab the scepter of purpose and meaning from my doddering old hands a minute sooner than you need to!

Another colleague is retiring to Arizona after many years of family practice. He’s planning on working 3 days a week in a friend’s practice. I think his concept of retirement is much healthier, and I wish him well. The way I see it, work is like prednisone: You have to taper off very slowly, and sometimes you have to stay on a little bit forever.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

When I went into practice in 1989, patients used to comment about my youthful appearance. "I thought the arthritis doctor had to be old," they told me. The years rolled by, and those comments became much less frequent. Nowadays, patients are more likely to ask me if I have arthritis, rather than comment on my youthful appearance.

Sometimes patients come back to the office after a hiatus of several years and compliment me that I have not aged in the interval. One bit of blarney deserves another, so I deflect the compliment by telling them I’m well preserved, because my patients are so nice to me. One lady became sentimental and insisted that she had been seeing me for 30 years, and I had to disabuse her of this fantasy by reminding her that I have only been at my current practice for 19 years, although it feels like I’ve been here forever.

No matter how much I love my work, I have to face the fact that one day I won’t be able to inject creaky knees or mash on fibromyalgia tender points. All good things come to an end, and I’ll have to face the frightening specter of retirement. Although I feel great, my heart tells me that I am approaching old age. If I had my choice, I would tarry in middle age forever, but that isn’t one of the options on the multiple-choice test of life.

Petite reminders of my rusty vintage pop up all the time. Just the other day, a family practice resident with whom I was seeing patients, let out a small exclamation of horrified surprise when I pulled my beloved Palm Pilot out of my pocket. I use it for reminders as well as the handy epocrates program. The resident remarked, "I had one of those when I was a medical student," with the tone of voice of someone recalling some distant epoch. I’m the last holdout on the planet without a smartphone, and I could tell from his slightly shocked demeanor that I looked completely "retro" sporting a gadget more suitable for the last millennium. I might just as well have pulled a slide rule out of my pocket.

I’m aging, but I have plenty of company for the journey. One of my colleagues is a silver-haired neurologist. Anytime one of my patients has an EMG, and tells me the doctor was old, I know exactly who they mean. He’s a sharp cookie, but younger patients are suspicious that older doctors are out of touch with cutting-edge medicine. That attitude bothers me more these days, and I know it is only a matter of time before my younger patients view me with the same prejudice. Put yourself in the place of a younger patient visiting a senior doctor. You ask a question, and the doctor consults a Palm Pilot instead of an iPhone. Does that shake your level of trust in the old codger’s answer?

Are senescence and retirement inevitable features of old age? Does chronology rule my destiny? My patients have taught me many valuable lessons, but perhaps I wasn’t paying attention when they taught me the "indications" for retirement. I often remind patients that they need to do something meaningful after they retire. Many of my retired patients are quite content with their hobbies or tending to their grandchildren. Parenthetically, when I see patients who are new to the neighborhood, I can usually guess their motivation for moving. Young people move here for jobs, and older people move here to be closer to their grandchildren. Grandchildren are the tail that wags the dog for seniors.

A retired factory worker who gets bored sitting at home can take a part-time job driving a truck, or work as a greeter at Walmart, but that won’t cut it for a physician. It’s much harder for a doctor to come to grips with the end of a career than it is for other professionals. A thousand daily seductions beguile us into believing we are indispensable, but how can our lives remain meaningful, if our patients no longer need us? During our careers, patients clamor to see us, and they are petulant when we are not available. Smartly dressed drug reps line our hallways and wait patiently for a minute or two of our time. Like it or not, all of this attention goes to our heads. We may strive to act humbly, but we understand that we are very important in the lives of many people. We use our skills to heal, and that gratification, which is unique to the medical profession, is very addictive. I realize that the world will not stop turning if I am not there to refill prescriptions and give technical support for the human body, but how do doctors bow out gracefully?

For some doctors, retirement is a punishment, like solitary confinement. I remember one orthopedist who retired early, while I was knee deep with things to do at the office. Later I heard through the grapevine that he died young from cancer, so that curbed any feelings of jealousy I may have harbored. I’m not suggesting that if he had continued to work he could have dodged the bullet, but I’m suspicious that the secret of youth is acting the role. In my mind’s eye I picture the fearful spectacle of my retirement party. Other professionals get a golden watch for a retirement gift. A golden goniometer is more appropriate for a rheumatologist, but I’m deathly afraid to accept it. Don’t grab the scepter of purpose and meaning from my doddering old hands a minute sooner than you need to!

Another colleague is retiring to Arizona after many years of family practice. He’s planning on working 3 days a week in a friend’s practice. I think his concept of retirement is much healthier, and I wish him well. The way I see it, work is like prednisone: You have to taper off very slowly, and sometimes you have to stay on a little bit forever.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Of all the malapropisms I learned in my training, calling gout "the gouch" is my favorite, since it captures vividly the unhappy nature of this ailment. The 43-year-old man whom I saw for a follow-up visit was certainly unhappy. Everywhere I looked I found swollen, tender joints; large effusions in his knees; tophi; extremely limited hand function; and difficulty walking. He was unhappy, and he let me know it.

"I’m doing everything that I’m supposed to, but I’m not getting any better."

In the face of these accusations, I decided to take a better look at his chart in the hopes that I’d find something to help guide his treatment. His gout was so bad, and his uric acid was so high, that I was concerned he might have some sort of myeloproliferative disorder. I ordered additional labs and I wasted some time looking for the results before I asked the obvious question. "Did you do those labs that I ordered?" I got a sheepish reply of "no." It turned out that he wasn’t taking his allopurinol either. So, Mr. I’m-doing-everything-that-I’m-supposed-to-do-but-I’m-not-getting-any-better had not done his labs or started his medication. If you can figure that out, let me know.

Compliance was obviously not his forte.

I can’t help but wonder how health care reform will ever work if we can’t find creative ways to get our patients to follow instructions. Some of my patients who work for one of the local hospitals get a discount on their health insurance if they maintain a normal weight and refrain from smoking. The insurance does urine testing to make sure that they are not smoking, but I’m still in the dark ages and rely on the honor system by asking my patients if they are smoking or not.

I doubt that doing urine screens for colchicine and allopurinol will be feasible, but it would be really easy for insurers to check our electronic prescriptions against the pharmacies’ electronic records. If a year goes by and the patient only buys enough medication for a month or two, that is a marvelously helpful bit of information.

I had a little taste of that once. I had a patient who was on three different gout medications but continued to do poorly. I was at my wits end trying to solve his problem until I had the nurse call the pharmacy and we found out that he wasn’t filling his prescriptions regularly.

A friend told me, "I take my medication religiously." After a brief pause he added the qualifying phrase, "Once a year!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Of all the malapropisms I learned in my training, calling gout "the gouch" is my favorite, since it captures vividly the unhappy nature of this ailment. The 43-year-old man whom I saw for a follow-up visit was certainly unhappy. Everywhere I looked I found swollen, tender joints; large effusions in his knees; tophi; extremely limited hand function; and difficulty walking. He was unhappy, and he let me know it.

"I’m doing everything that I’m supposed to, but I’m not getting any better."

In the face of these accusations, I decided to take a better look at his chart in the hopes that I’d find something to help guide his treatment. His gout was so bad, and his uric acid was so high, that I was concerned he might have some sort of myeloproliferative disorder. I ordered additional labs and I wasted some time looking for the results before I asked the obvious question. "Did you do those labs that I ordered?" I got a sheepish reply of "no." It turned out that he wasn’t taking his allopurinol either. So, Mr. I’m-doing-everything-that-I’m-supposed-to-do-but-I’m-not-getting-any-better had not done his labs or started his medication. If you can figure that out, let me know.

Compliance was obviously not his forte.

I can’t help but wonder how health care reform will ever work if we can’t find creative ways to get our patients to follow instructions. Some of my patients who work for one of the local hospitals get a discount on their health insurance if they maintain a normal weight and refrain from smoking. The insurance does urine testing to make sure that they are not smoking, but I’m still in the dark ages and rely on the honor system by asking my patients if they are smoking or not.

I doubt that doing urine screens for colchicine and allopurinol will be feasible, but it would be really easy for insurers to check our electronic prescriptions against the pharmacies’ electronic records. If a year goes by and the patient only buys enough medication for a month or two, that is a marvelously helpful bit of information.

I had a little taste of that once. I had a patient who was on three different gout medications but continued to do poorly. I was at my wits end trying to solve his problem until I had the nurse call the pharmacy and we found out that he wasn’t filling his prescriptions regularly.

A friend told me, "I take my medication religiously." After a brief pause he added the qualifying phrase, "Once a year!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Of all the malapropisms I learned in my training, calling gout "the gouch" is my favorite, since it captures vividly the unhappy nature of this ailment. The 43-year-old man whom I saw for a follow-up visit was certainly unhappy. Everywhere I looked I found swollen, tender joints; large effusions in his knees; tophi; extremely limited hand function; and difficulty walking. He was unhappy, and he let me know it.

"I’m doing everything that I’m supposed to, but I’m not getting any better."

In the face of these accusations, I decided to take a better look at his chart in the hopes that I’d find something to help guide his treatment. His gout was so bad, and his uric acid was so high, that I was concerned he might have some sort of myeloproliferative disorder. I ordered additional labs and I wasted some time looking for the results before I asked the obvious question. "Did you do those labs that I ordered?" I got a sheepish reply of "no." It turned out that he wasn’t taking his allopurinol either. So, Mr. I’m-doing-everything-that-I’m-supposed-to-do-but-I’m-not-getting-any-better had not done his labs or started his medication. If you can figure that out, let me know.

Compliance was obviously not his forte.

I can’t help but wonder how health care reform will ever work if we can’t find creative ways to get our patients to follow instructions. Some of my patients who work for one of the local hospitals get a discount on their health insurance if they maintain a normal weight and refrain from smoking. The insurance does urine testing to make sure that they are not smoking, but I’m still in the dark ages and rely on the honor system by asking my patients if they are smoking or not.

I doubt that doing urine screens for colchicine and allopurinol will be feasible, but it would be really easy for insurers to check our electronic prescriptions against the pharmacies’ electronic records. If a year goes by and the patient only buys enough medication for a month or two, that is a marvelously helpful bit of information.

I had a little taste of that once. I had a patient who was on three different gout medications but continued to do poorly. I was at my wits end trying to solve his problem until I had the nurse call the pharmacy and we found out that he wasn’t filling his prescriptions regularly.

A friend told me, "I take my medication religiously." After a brief pause he added the qualifying phrase, "Once a year!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

A good doctor prescribes medication and helps a patient get better, but a better option is to discontinue medication if it is causing the patient’s problems. Although that scenario is generally gratifying for both the doctor and the patient, it’s not always as easy as it sounds.

Consider a 75-year-old woman whom I saw recently. She had lots of complaints but topping her list of sorrows were alopecia and xerostomia. Her hair loss had gradually gotten worse over the last 5 to 6 years.

Her dermatologist had suggested that she use topical minoxidil, but she wasn’t happy with this advice. Another rheumatologist had her use pilocarpine for her dry mouth, but it didn’t help, and cevimeline was too expensive. I had seen her once a few years earlier for unrelated problems, and she decided to return to see me regarding a positive ANA (antinuclear antibody) her primary physician had drawn.

Her past medical history included diagnoses of fibromyalgia, osteoarthritis, osteoporosis, multiple sclerosis, and depression. She was anxious and, given her ever-lengthening list of diagnoses, doctors, and medications, she had good reason to feel anxious.

She might have Sjögren’s syndrome, but citalopram was on her medication list, and I thought her problems might be drug related. She had been on citalopram for years. An on-line drug reference listed alopecia and xerostomia as possible side effects of this medication. I told her that I couldn’t be sure that citalopram was the cause of her woes, but it was a possibility. Before labeling her with Sjögren’s syndrome and prescribing medication for that diagnosis, I wanted to know if she got better by stopping citalopram rather than by adding a medication to her already long list of pills.

She gladly accepted this proposal, but she was definitely a nervous individual. Watching her fidget, the best adjective that popped into my charitable mind was "squirrelly." Although there isn’t an official billing code for this diagnosis, there should be. What might happen if I took away her nerve medication? Would her family doctor think I had lost my mind? Could her family cope with her undiluted personality once she was off her medication? These questions all bothered me, but we went ahead with the program. She came back a month later with a new set of gripes.

I asked her if she had any problem getting off the citalopram. She said she was unhappy because I didn’t give her instructions about tapering off her medication. I had been on vacation in the interim, and she accused me of "going off to Disney World!" Her husband was there in the exam room with us as was a family practice resident, so there were two spectators to this small clinical melee.

Before responding to her complaint regarding her medication instructions, I felt that I had to clear myself of the heinous accusation of abandoning her while I cavorted in Disney World! I have pleaded with my staff previously, to avoid using the "V word" (vacation) with my patients. It really gets under my skin when I come back to the office after a vacation and patients ask me how my vacation was or where I went. With most patients, those questions are just casual chitchat, but other patients have a cold sneering edge to their voice. Their implication is "I was suffering while you were playing." I guess it is invariable that patients find out about my outings when they can’t get appointments or the staff has to change their appointments, but I still don’t like it. I had made a short pilgrimage home to visit family and friends whom I hadn’t seen in a long time. Even though I knew the notion that I had gone to Disney was just a manifestation of this patient’s intrinsic goofiness, I could feel her burrowing under my calm clinical defense perimeter, and pushing my buttons in a big way. Her squirrelly personality was rubbing off on me.

I looked through her chart, and found her instructions. "At your last visit, you couldn’t remember your dose of citalopram, so you had to call back and let us know that you were taking 40 mg a day. I wrote instructions for tapering off that dosage, and the nurse left a message on your answering machine that afternoon."

She said she never got the message, and she again accused me of fleeing to Disney World. By this time, Disney World was starting to sound increasingly attractive. I wasn’t quite sure why she looked different, but I had noticed that she looked better as soon as I opened the exam room door. She told me her hair loss was a little better, and she had her hair professionally colored for the first time in many months. Her hairdresser really did know for sure!

Her dry mouth symptoms were about the same, but unfortunately not bad enough to keep her from talking. Her anxiety didn’t seem any worse, even though she had tapered her citalopram by 75%. I gave her instructions for tapering off the citalopram entirely, in the vain hope that she would keep visiting the hairdresser instead of me.

She reluctantly conceded that I hadn’t gone to Disney World, but she wouldn’t let me out of the room until I checked her husband. Her husband wasn’t even my patient, but she was terribly worried about a skin lesion on his left arm. He had on a short-sleeve shirt and, by this time, I would have done anything to escape, so I glanced at his bare left forearm and didn’t see anything unusual. Her husband also seemed startled by his wife’s request, so she reminded him that the problem was in his underarm. I should have protested or charged him for my trouble, but luckily it was just a small lipoma. I reassured them both for the same low price and finally beat a retreat.

The squirrel phoned a few weeks later and said that she wanted to resume citalopram. I had the nurse remind her why I had her go off the medication, with instructions to follow-up with her family doctor. He’s probably wondering what got into me, or perhaps he thinks I have gotten squirrelly in my old age.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

A good doctor prescribes medication and helps a patient get better, but a better option is to discontinue medication if it is causing the patient’s problems. Although that scenario is generally gratifying for both the doctor and the patient, it’s not always as easy as it sounds.

Consider a 75-year-old woman whom I saw recently. She had lots of complaints but topping her list of sorrows were alopecia and xerostomia. Her hair loss had gradually gotten worse over the last 5 to 6 years.

Her dermatologist had suggested that she use topical minoxidil, but she wasn’t happy with this advice. Another rheumatologist had her use pilocarpine for her dry mouth, but it didn’t help, and cevimeline was too expensive. I had seen her once a few years earlier for unrelated problems, and she decided to return to see me regarding a positive ANA (antinuclear antibody) her primary physician had drawn.

Her past medical history included diagnoses of fibromyalgia, osteoarthritis, osteoporosis, multiple sclerosis, and depression. She was anxious and, given her ever-lengthening list of diagnoses, doctors, and medications, she had good reason to feel anxious.

She might have Sjögren’s syndrome, but citalopram was on her medication list, and I thought her problems might be drug related. She had been on citalopram for years. An on-line drug reference listed alopecia and xerostomia as possible side effects of this medication. I told her that I couldn’t be sure that citalopram was the cause of her woes, but it was a possibility. Before labeling her with Sjögren’s syndrome and prescribing medication for that diagnosis, I wanted to know if she got better by stopping citalopram rather than by adding a medication to her already long list of pills.

She gladly accepted this proposal, but she was definitely a nervous individual. Watching her fidget, the best adjective that popped into my charitable mind was "squirrelly." Although there isn’t an official billing code for this diagnosis, there should be. What might happen if I took away her nerve medication? Would her family doctor think I had lost my mind? Could her family cope with her undiluted personality once she was off her medication? These questions all bothered me, but we went ahead with the program. She came back a month later with a new set of gripes.

I asked her if she had any problem getting off the citalopram. She said she was unhappy because I didn’t give her instructions about tapering off her medication. I had been on vacation in the interim, and she accused me of "going off to Disney World!" Her husband was there in the exam room with us as was a family practice resident, so there were two spectators to this small clinical melee.

Before responding to her complaint regarding her medication instructions, I felt that I had to clear myself of the heinous accusation of abandoning her while I cavorted in Disney World! I have pleaded with my staff previously, to avoid using the "V word" (vacation) with my patients. It really gets under my skin when I come back to the office after a vacation and patients ask me how my vacation was or where I went. With most patients, those questions are just casual chitchat, but other patients have a cold sneering edge to their voice. Their implication is "I was suffering while you were playing." I guess it is invariable that patients find out about my outings when they can’t get appointments or the staff has to change their appointments, but I still don’t like it. I had made a short pilgrimage home to visit family and friends whom I hadn’t seen in a long time. Even though I knew the notion that I had gone to Disney was just a manifestation of this patient’s intrinsic goofiness, I could feel her burrowing under my calm clinical defense perimeter, and pushing my buttons in a big way. Her squirrelly personality was rubbing off on me.

I looked through her chart, and found her instructions. "At your last visit, you couldn’t remember your dose of citalopram, so you had to call back and let us know that you were taking 40 mg a day. I wrote instructions for tapering off that dosage, and the nurse left a message on your answering machine that afternoon."

She said she never got the message, and she again accused me of fleeing to Disney World. By this time, Disney World was starting to sound increasingly attractive. I wasn’t quite sure why she looked different, but I had noticed that she looked better as soon as I opened the exam room door. She told me her hair loss was a little better, and she had her hair professionally colored for the first time in many months. Her hairdresser really did know for sure!

Her dry mouth symptoms were about the same, but unfortunately not bad enough to keep her from talking. Her anxiety didn’t seem any worse, even though she had tapered her citalopram by 75%. I gave her instructions for tapering off the citalopram entirely, in the vain hope that she would keep visiting the hairdresser instead of me.

She reluctantly conceded that I hadn’t gone to Disney World, but she wouldn’t let me out of the room until I checked her husband. Her husband wasn’t even my patient, but she was terribly worried about a skin lesion on his left arm. He had on a short-sleeve shirt and, by this time, I would have done anything to escape, so I glanced at his bare left forearm and didn’t see anything unusual. Her husband also seemed startled by his wife’s request, so she reminded him that the problem was in his underarm. I should have protested or charged him for my trouble, but luckily it was just a small lipoma. I reassured them both for the same low price and finally beat a retreat.

The squirrel phoned a few weeks later and said that she wanted to resume citalopram. I had the nurse remind her why I had her go off the medication, with instructions to follow-up with her family doctor. He’s probably wondering what got into me, or perhaps he thinks I have gotten squirrelly in my old age.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

A good doctor prescribes medication and helps a patient get better, but a better option is to discontinue medication if it is causing the patient’s problems. Although that scenario is generally gratifying for both the doctor and the patient, it’s not always as easy as it sounds.

Consider a 75-year-old woman whom I saw recently. She had lots of complaints but topping her list of sorrows were alopecia and xerostomia. Her hair loss had gradually gotten worse over the last 5 to 6 years.

Her dermatologist had suggested that she use topical minoxidil, but she wasn’t happy with this advice. Another rheumatologist had her use pilocarpine for her dry mouth, but it didn’t help, and cevimeline was too expensive. I had seen her once a few years earlier for unrelated problems, and she decided to return to see me regarding a positive ANA (antinuclear antibody) her primary physician had drawn.

Her past medical history included diagnoses of fibromyalgia, osteoarthritis, osteoporosis, multiple sclerosis, and depression. She was anxious and, given her ever-lengthening list of diagnoses, doctors, and medications, she had good reason to feel anxious.

She might have Sjögren’s syndrome, but citalopram was on her medication list, and I thought her problems might be drug related. She had been on citalopram for years. An on-line drug reference listed alopecia and xerostomia as possible side effects of this medication. I told her that I couldn’t be sure that citalopram was the cause of her woes, but it was a possibility. Before labeling her with Sjögren’s syndrome and prescribing medication for that diagnosis, I wanted to know if she got better by stopping citalopram rather than by adding a medication to her already long list of pills.

She gladly accepted this proposal, but she was definitely a nervous individual. Watching her fidget, the best adjective that popped into my charitable mind was "squirrelly." Although there isn’t an official billing code for this diagnosis, there should be. What might happen if I took away her nerve medication? Would her family doctor think I had lost my mind? Could her family cope with her undiluted personality once she was off her medication? These questions all bothered me, but we went ahead with the program. She came back a month later with a new set of gripes.

I asked her if she had any problem getting off the citalopram. She said she was unhappy because I didn’t give her instructions about tapering off her medication. I had been on vacation in the interim, and she accused me of "going off to Disney World!" Her husband was there in the exam room with us as was a family practice resident, so there were two spectators to this small clinical melee.

Before responding to her complaint regarding her medication instructions, I felt that I had to clear myself of the heinous accusation of abandoning her while I cavorted in Disney World! I have pleaded with my staff previously, to avoid using the "V word" (vacation) with my patients. It really gets under my skin when I come back to the office after a vacation and patients ask me how my vacation was or where I went. With most patients, those questions are just casual chitchat, but other patients have a cold sneering edge to their voice. Their implication is "I was suffering while you were playing." I guess it is invariable that patients find out about my outings when they can’t get appointments or the staff has to change their appointments, but I still don’t like it. I had made a short pilgrimage home to visit family and friends whom I hadn’t seen in a long time. Even though I knew the notion that I had gone to Disney was just a manifestation of this patient’s intrinsic goofiness, I could feel her burrowing under my calm clinical defense perimeter, and pushing my buttons in a big way. Her squirrelly personality was rubbing off on me.

I looked through her chart, and found her instructions. "At your last visit, you couldn’t remember your dose of citalopram, so you had to call back and let us know that you were taking 40 mg a day. I wrote instructions for tapering off that dosage, and the nurse left a message on your answering machine that afternoon."

She said she never got the message, and she again accused me of fleeing to Disney World. By this time, Disney World was starting to sound increasingly attractive. I wasn’t quite sure why she looked different, but I had noticed that she looked better as soon as I opened the exam room door. She told me her hair loss was a little better, and she had her hair professionally colored for the first time in many months. Her hairdresser really did know for sure!

Her dry mouth symptoms were about the same, but unfortunately not bad enough to keep her from talking. Her anxiety didn’t seem any worse, even though she had tapered her citalopram by 75%. I gave her instructions for tapering off the citalopram entirely, in the vain hope that she would keep visiting the hairdresser instead of me.

She reluctantly conceded that I hadn’t gone to Disney World, but she wouldn’t let me out of the room until I checked her husband. Her husband wasn’t even my patient, but she was terribly worried about a skin lesion on his left arm. He had on a short-sleeve shirt and, by this time, I would have done anything to escape, so I glanced at his bare left forearm and didn’t see anything unusual. Her husband also seemed startled by his wife’s request, so she reminded him that the problem was in his underarm. I should have protested or charged him for my trouble, but luckily it was just a small lipoma. I reassured them both for the same low price and finally beat a retreat.

The squirrel phoned a few weeks later and said that she wanted to resume citalopram. I had the nurse remind her why I had her go off the medication, with instructions to follow-up with her family doctor. He’s probably wondering what got into me, or perhaps he thinks I have gotten squirrelly in my old age.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

The overweight 72-year-old woman whom I saw in clinic was miserable because of osteoarthritis in both her knees.

Like so many other patients with these complaints, she had tried numerous NSAIDs that either didn’t help or came with intolerable side effects. Knee injections with corticosteroids, as well as hyaluronic acid, were both disappointing failures. Like most 72 year olds, she didn’t want knee replacement surgery if she could avoid it.

After this dismal track record, I tried to find an analgesic that would help without causing dreadful side effects. Neither tramadol nor hydrocodone had worked well, so at her last visit I prescribed oxycodone. I prescribed enough of the medication for her to take four tablets a day. Despite this, she came back to see me and she was still miserable, unhappy, and discouraged.

I investigated the reasons for the latest treatment failure, and what I found out did not please me one bit: Even though the prescription was clearly labeled with instructions to take up to four a day if needed, she was taking only two tablets a day.

Normally, when I find patients underutilizing pain medication, it is because of GI side effects, cognitive impairment, or fear of addiction. My patient didn’t have any of these problems. She was afraid to take four tablets a day because the pharmacist told her four a day would put her at high risk for GI bleeding.

"Why did you ask the pharmacist instead of me?" I bleated plaintively. I try really hard to never get irritated with patients, but sometimes patients find creative new ways of pushing my buttons, despite my attempts to maintain a sunny and supportive countenance. Even as the petulant query went whizzing out of my mouth, I regretted asking it, and I already knew the answer.

Patients would much rather ask the doctor than the pharmacist, but the pharmacist is readily accessible. The patient can just sidle up to the counter at the pharmacy. After a few minutes the friendly pharmacist speaks with the patient face to face – and free of charge!

By contrast, it is almost never so easy to speak with the doctor. A patient has to make her way past the answering service, the nurse, and the practice administrator. After those initial hurdles, the patient has to wait hour – or even days – for a reply. Like it or not, if we aren’t easily accessible to supply answers to our patient’s questions, someone else will be happy to do it for us.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

The overweight 72-year-old woman whom I saw in clinic was miserable because of osteoarthritis in both her knees.

Like so many other patients with these complaints, she had tried numerous NSAIDs that either didn’t help or came with intolerable side effects. Knee injections with corticosteroids, as well as hyaluronic acid, were both disappointing failures. Like most 72 year olds, she didn’t want knee replacement surgery if she could avoid it.

After this dismal track record, I tried to find an analgesic that would help without causing dreadful side effects. Neither tramadol nor hydrocodone had worked well, so at her last visit I prescribed oxycodone. I prescribed enough of the medication for her to take four tablets a day. Despite this, she came back to see me and she was still miserable, unhappy, and discouraged.

I investigated the reasons for the latest treatment failure, and what I found out did not please me one bit: Even though the prescription was clearly labeled with instructions to take up to four a day if needed, she was taking only two tablets a day.

Normally, when I find patients underutilizing pain medication, it is because of GI side effects, cognitive impairment, or fear of addiction. My patient didn’t have any of these problems. She was afraid to take four tablets a day because the pharmacist told her four a day would put her at high risk for GI bleeding.

"Why did you ask the pharmacist instead of me?" I bleated plaintively. I try really hard to never get irritated with patients, but sometimes patients find creative new ways of pushing my buttons, despite my attempts to maintain a sunny and supportive countenance. Even as the petulant query went whizzing out of my mouth, I regretted asking it, and I already knew the answer.

Patients would much rather ask the doctor than the pharmacist, but the pharmacist is readily accessible. The patient can just sidle up to the counter at the pharmacy. After a few minutes the friendly pharmacist speaks with the patient face to face – and free of charge!

By contrast, it is almost never so easy to speak with the doctor. A patient has to make her way past the answering service, the nurse, and the practice administrator. After those initial hurdles, the patient has to wait hour – or even days – for a reply. Like it or not, if we aren’t easily accessible to supply answers to our patient’s questions, someone else will be happy to do it for us.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

The overweight 72-year-old woman whom I saw in clinic was miserable because of osteoarthritis in both her knees.

Like so many other patients with these complaints, she had tried numerous NSAIDs that either didn’t help or came with intolerable side effects. Knee injections with corticosteroids, as well as hyaluronic acid, were both disappointing failures. Like most 72 year olds, she didn’t want knee replacement surgery if she could avoid it.

After this dismal track record, I tried to find an analgesic that would help without causing dreadful side effects. Neither tramadol nor hydrocodone had worked well, so at her last visit I prescribed oxycodone. I prescribed enough of the medication for her to take four tablets a day. Despite this, she came back to see me and she was still miserable, unhappy, and discouraged.

I investigated the reasons for the latest treatment failure, and what I found out did not please me one bit: Even though the prescription was clearly labeled with instructions to take up to four a day if needed, she was taking only two tablets a day.

Normally, when I find patients underutilizing pain medication, it is because of GI side effects, cognitive impairment, or fear of addiction. My patient didn’t have any of these problems. She was afraid to take four tablets a day because the pharmacist told her four a day would put her at high risk for GI bleeding.

"Why did you ask the pharmacist instead of me?" I bleated plaintively. I try really hard to never get irritated with patients, but sometimes patients find creative new ways of pushing my buttons, despite my attempts to maintain a sunny and supportive countenance. Even as the petulant query went whizzing out of my mouth, I regretted asking it, and I already knew the answer.

Patients would much rather ask the doctor than the pharmacist, but the pharmacist is readily accessible. The patient can just sidle up to the counter at the pharmacy. After a few minutes the friendly pharmacist speaks with the patient face to face – and free of charge!

By contrast, it is almost never so easy to speak with the doctor. A patient has to make her way past the answering service, the nurse, and the practice administrator. After those initial hurdles, the patient has to wait hour – or even days – for a reply. Like it or not, if we aren’t easily accessible to supply answers to our patient’s questions, someone else will be happy to do it for us.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Patients never ask me if I’m maintaining their medical records properly, even though this is an important part of what doctors do. Occasionally I mention this to patients, but they always give me a blank look.

Quality medical records allow for portable care. Clear and well-organized records allow the next doc to take over where the previous doc left off. The main impediment to the smooth transfer of care used to be doctors’ bad handwriting. Handwritten notes are becoming a thing of the past, but nowadays we struggle with a different set of challenges.

I’m one of those old curmudgeons who prefer written communication to be as clear and brief as possible. If my English teachers could see me now, they’d be proud. When I was new in practice, I had my reports typed as rough drafts so I could make corrections with a red pen, but as my practice grew, this labor-intensive practice became impossible. These days, medical dictation is rarely proofread by the doctor, unless the patient is a celebrity or a VIP.

Referring physicians used to send consultants a cover letter with the patient’s records. This note summarized the patient’s problems and explained why the referring doctor was sending the patient to the consultant. That sort of courtesy is also a rarity these days, and often the hapless patient is left to explain the reason for their visit, although the pitfalls of this lack of communication between the referring physician and the consultant are obvious.

Unfortunately, electronic medical records (EMRs) are often an amorphous mass of unorganized data and a poor substitute for direct communication from the referring practitioner. Consider the following excerpt of an EMR that a nurse practitioner sent me regarding a new patient:

"The patient is doing well this past month. No new problems. Pt states PCP decreased her Synthroid from 115 to .88 cc mcg over the past year; reports increased fatigue. She reports increased generalized pain; forgot to change patch for 24 hours and had increase pain. She denies new pain or injury. Will f/u with PCP within the next six weeks. Sleep is good, averages 10 to 11 hours of sleep. Bowels move daily with 100 to 120 oz’s of water, fluids, diet, and Yogurt. I feel oversedated No. I have a new medical problem No. I have run out of my meds No. I have reported lost or stolen meds No."

This stream of consciousness went on and on, but I think you get the gist of my dissatisfaction. Computer-assisted record keeping can produce notes that are dense, rambling, and sometimes even nonsensical.

EMRs also add large amounts of data that don’t belong in progress notes. Notes from a referring doctor describing a middle-aged woman with back pain had a long, obscure paragraph identifying the ICD-9 billing codes that were applicable for her problems. Perhaps that information is helpful for the billing department, but it doesn’t belong in a progress note. It is equally frustrating trying to print a lab or x-ray report from the hospital’s EMRs. What should be a 1-page report is usually bloated into a 10-page manifesto.

New patients often come to see me with thick packets of photocopied records. Sitting there as I silently and rapidly flip pages, the patient looks at me hoping that I am finding information that will help them. Perhaps they think I am speed reading, or careless. The truth is that I am doing a paper triage, trying to separate the useful information from the chaff. Usually a small amount of clinically relevant information has been spread over a vast number of pages.

I recently saw a young man with complaints of fatigue. The referring physician sent me a printout of the EMR, which included a detailed physical exam including details of the external and internal gynecologic exam. Undoubtedly, the referring doctor clicked on the wrong link when he used the EMR to create his report, causing the computer to spew out the boilerplate dictation for a physical exam of female genitalia. We can laugh about such silly mistakes, but that sort of thing makes us look careless and detached.

Many doctors are too busy to enter information directly into the EMR, and instead use a "scribe" to take notes and transfer information into the EMR. This adds another person in the exam room. It’s a shoddy practice, and it infringes on the doctor-patient relationship.

Hospitals’ progress notes can be bloated with information. Having good information is important, but having the computer import the patient’s medication list, pages of labs, and radiology reports that the author didn’t review is a dishonest practice. We could just as easily have the computer throw in a few textbook chapters for each diagnosis code. Wouldn’t that look splendid and justify billing for a higher level of service? As useful as this information bolus might be, without a sentient being to coalesce it into coherence, it is just a data tsunami.

The presentation of lab data in EMRs can sometimes be especially annoying. I recently saw a patient who arrived with a long list of alphabetized lab reports: "MCV, Monocyte %, Na, neutrophil, plt, protein ..." and so on. Presenting the labs alphabetically had effectively shuffled together a CBC, basic metabolic profile, and whatever other test results the patient had. Even a junior medical student wouldn’t do this. I scrolled and scrolled, hoping to find some meaningful assessment of the patient’s problems and progress, but I just couldn’t find anything to show me that some thought went into the lengthy final product.

I frequently get hospital discharge summaries that don’t include the date of the patient’s discharge. How lame is that? Often, I have to try to reconstruct hospital events from the information I can glean from the patient. One long rambling note included the very helpful assessment and plan: "Mary was seen today for other."

The Zenith slogan proclaims, "The quality goes in before the name goes on." Patient records, over which we slave, document the quality of our care; I want them to be clear and accurate before I let some computer sign my name on the bottom line. But hey, don’t shoot me – I’m just the scribe.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Patients never ask me if I’m maintaining their medical records properly, even though this is an important part of what doctors do. Occasionally I mention this to patients, but they always give me a blank look.

Quality medical records allow for portable care. Clear and well-organized records allow the next doc to take over where the previous doc left off. The main impediment to the smooth transfer of care used to be doctors’ bad handwriting. Handwritten notes are becoming a thing of the past, but nowadays we struggle with a different set of challenges.

I’m one of those old curmudgeons who prefer written communication to be as clear and brief as possible. If my English teachers could see me now, they’d be proud. When I was new in practice, I had my reports typed as rough drafts so I could make corrections with a red pen, but as my practice grew, this labor-intensive practice became impossible. These days, medical dictation is rarely proofread by the doctor, unless the patient is a celebrity or a VIP.

Referring physicians used to send consultants a cover letter with the patient’s records. This note summarized the patient’s problems and explained why the referring doctor was sending the patient to the consultant. That sort of courtesy is also a rarity these days, and often the hapless patient is left to explain the reason for their visit, although the pitfalls of this lack of communication between the referring physician and the consultant are obvious.

Unfortunately, electronic medical records (EMRs) are often an amorphous mass of unorganized data and a poor substitute for direct communication from the referring practitioner. Consider the following excerpt of an EMR that a nurse practitioner sent me regarding a new patient:

"The patient is doing well this past month. No new problems. Pt states PCP decreased her Synthroid from 115 to .88 cc mcg over the past year; reports increased fatigue. She reports increased generalized pain; forgot to change patch for 24 hours and had increase pain. She denies new pain or injury. Will f/u with PCP within the next six weeks. Sleep is good, averages 10 to 11 hours of sleep. Bowels move daily with 100 to 120 oz’s of water, fluids, diet, and Yogurt. I feel oversedated No. I have a new medical problem No. I have run out of my meds No. I have reported lost or stolen meds No."

This stream of consciousness went on and on, but I think you get the gist of my dissatisfaction. Computer-assisted record keeping can produce notes that are dense, rambling, and sometimes even nonsensical.

EMRs also add large amounts of data that don’t belong in progress notes. Notes from a referring doctor describing a middle-aged woman with back pain had a long, obscure paragraph identifying the ICD-9 billing codes that were applicable for her problems. Perhaps that information is helpful for the billing department, but it doesn’t belong in a progress note. It is equally frustrating trying to print a lab or x-ray report from the hospital’s EMRs. What should be a 1-page report is usually bloated into a 10-page manifesto.

New patients often come to see me with thick packets of photocopied records. Sitting there as I silently and rapidly flip pages, the patient looks at me hoping that I am finding information that will help them. Perhaps they think I am speed reading, or careless. The truth is that I am doing a paper triage, trying to separate the useful information from the chaff. Usually a small amount of clinically relevant information has been spread over a vast number of pages.

I recently saw a young man with complaints of fatigue. The referring physician sent me a printout of the EMR, which included a detailed physical exam including details of the external and internal gynecologic exam. Undoubtedly, the referring doctor clicked on the wrong link when he used the EMR to create his report, causing the computer to spew out the boilerplate dictation for a physical exam of female genitalia. We can laugh about such silly mistakes, but that sort of thing makes us look careless and detached.

Many doctors are too busy to enter information directly into the EMR, and instead use a "scribe" to take notes and transfer information into the EMR. This adds another person in the exam room. It’s a shoddy practice, and it infringes on the doctor-patient relationship.

Hospitals’ progress notes can be bloated with information. Having good information is important, but having the computer import the patient’s medication list, pages of labs, and radiology reports that the author didn’t review is a dishonest practice. We could just as easily have the computer throw in a few textbook chapters for each diagnosis code. Wouldn’t that look splendid and justify billing for a higher level of service? As useful as this information bolus might be, without a sentient being to coalesce it into coherence, it is just a data tsunami.

The presentation of lab data in EMRs can sometimes be especially annoying. I recently saw a patient who arrived with a long list of alphabetized lab reports: "MCV, Monocyte %, Na, neutrophil, plt, protein ..." and so on. Presenting the labs alphabetically had effectively shuffled together a CBC, basic metabolic profile, and whatever other test results the patient had. Even a junior medical student wouldn’t do this. I scrolled and scrolled, hoping to find some meaningful assessment of the patient’s problems and progress, but I just couldn’t find anything to show me that some thought went into the lengthy final product.

I frequently get hospital discharge summaries that don’t include the date of the patient’s discharge. How lame is that? Often, I have to try to reconstruct hospital events from the information I can glean from the patient. One long rambling note included the very helpful assessment and plan: "Mary was seen today for other."

The Zenith slogan proclaims, "The quality goes in before the name goes on." Patient records, over which we slave, document the quality of our care; I want them to be clear and accurate before I let some computer sign my name on the bottom line. But hey, don’t shoot me – I’m just the scribe.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Patients never ask me if I’m maintaining their medical records properly, even though this is an important part of what doctors do. Occasionally I mention this to patients, but they always give me a blank look.

Quality medical records allow for portable care. Clear and well-organized records allow the next doc to take over where the previous doc left off. The main impediment to the smooth transfer of care used to be doctors’ bad handwriting. Handwritten notes are becoming a thing of the past, but nowadays we struggle with a different set of challenges.

I’m one of those old curmudgeons who prefer written communication to be as clear and brief as possible. If my English teachers could see me now, they’d be proud. When I was new in practice, I had my reports typed as rough drafts so I could make corrections with a red pen, but as my practice grew, this labor-intensive practice became impossible. These days, medical dictation is rarely proofread by the doctor, unless the patient is a celebrity or a VIP.

Referring physicians used to send consultants a cover letter with the patient’s records. This note summarized the patient’s problems and explained why the referring doctor was sending the patient to the consultant. That sort of courtesy is also a rarity these days, and often the hapless patient is left to explain the reason for their visit, although the pitfalls of this lack of communication between the referring physician and the consultant are obvious.

Unfortunately, electronic medical records (EMRs) are often an amorphous mass of unorganized data and a poor substitute for direct communication from the referring practitioner. Consider the following excerpt of an EMR that a nurse practitioner sent me regarding a new patient:

"The patient is doing well this past month. No new problems. Pt states PCP decreased her Synthroid from 115 to .88 cc mcg over the past year; reports increased fatigue. She reports increased generalized pain; forgot to change patch for 24 hours and had increase pain. She denies new pain or injury. Will f/u with PCP within the next six weeks. Sleep is good, averages 10 to 11 hours of sleep. Bowels move daily with 100 to 120 oz’s of water, fluids, diet, and Yogurt. I feel oversedated No. I have a new medical problem No. I have run out of my meds No. I have reported lost or stolen meds No."

This stream of consciousness went on and on, but I think you get the gist of my dissatisfaction. Computer-assisted record keeping can produce notes that are dense, rambling, and sometimes even nonsensical.

EMRs also add large amounts of data that don’t belong in progress notes. Notes from a referring doctor describing a middle-aged woman with back pain had a long, obscure paragraph identifying the ICD-9 billing codes that were applicable for her problems. Perhaps that information is helpful for the billing department, but it doesn’t belong in a progress note. It is equally frustrating trying to print a lab or x-ray report from the hospital’s EMRs. What should be a 1-page report is usually bloated into a 10-page manifesto.

New patients often come to see me with thick packets of photocopied records. Sitting there as I silently and rapidly flip pages, the patient looks at me hoping that I am finding information that will help them. Perhaps they think I am speed reading, or careless. The truth is that I am doing a paper triage, trying to separate the useful information from the chaff. Usually a small amount of clinically relevant information has been spread over a vast number of pages.

I recently saw a young man with complaints of fatigue. The referring physician sent me a printout of the EMR, which included a detailed physical exam including details of the external and internal gynecologic exam. Undoubtedly, the referring doctor clicked on the wrong link when he used the EMR to create his report, causing the computer to spew out the boilerplate dictation for a physical exam of female genitalia. We can laugh about such silly mistakes, but that sort of thing makes us look careless and detached.

Many doctors are too busy to enter information directly into the EMR, and instead use a "scribe" to take notes and transfer information into the EMR. This adds another person in the exam room. It’s a shoddy practice, and it infringes on the doctor-patient relationship.

Hospitals’ progress notes can be bloated with information. Having good information is important, but having the computer import the patient’s medication list, pages of labs, and radiology reports that the author didn’t review is a dishonest practice. We could just as easily have the computer throw in a few textbook chapters for each diagnosis code. Wouldn’t that look splendid and justify billing for a higher level of service? As useful as this information bolus might be, without a sentient being to coalesce it into coherence, it is just a data tsunami.

The presentation of lab data in EMRs can sometimes be especially annoying. I recently saw a patient who arrived with a long list of alphabetized lab reports: "MCV, Monocyte %, Na, neutrophil, plt, protein ..." and so on. Presenting the labs alphabetically had effectively shuffled together a CBC, basic metabolic profile, and whatever other test results the patient had. Even a junior medical student wouldn’t do this. I scrolled and scrolled, hoping to find some meaningful assessment of the patient’s problems and progress, but I just couldn’t find anything to show me that some thought went into the lengthy final product.

I frequently get hospital discharge summaries that don’t include the date of the patient’s discharge. How lame is that? Often, I have to try to reconstruct hospital events from the information I can glean from the patient. One long rambling note included the very helpful assessment and plan: "Mary was seen today for other."

The Zenith slogan proclaims, "The quality goes in before the name goes on." Patient records, over which we slave, document the quality of our care; I want them to be clear and accurate before I let some computer sign my name on the bottom line. But hey, don’t shoot me – I’m just the scribe.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Medicine would love to be an exact science, but the science of patients can never be exact, as you will see from this small tale of an 81-year-old woman. As a medical student, I always feared presenting patients like her on rounds. When a patient keeps changing key details of the history, it makes the student look like an incompetent idiot in front of the entire team. The professor gets upset and may even demote the trainee to the remedial medical unit.

This woman came to see me because her left hip was hurting. I asked her how long her hip had been hurting, and she told me that it was more than 2 weeks. I examined her and found good range of motion in her hip, but tenderness over the side of her hip, consistent with trochanteric bursitis.

While I was pondering what to do for her painful hip, she mentioned that her family doctor had injected it with cortisone 3 weeks ago, but the injection had not helped. I am not fond of injecting hips, and this absolved me of trying that remedy. This procedure requires a long needle, and a strong determination, but the results are frequently disappointing.

Although I didn’t have to inject her hip, I would have to do something, so I studied her chart more carefully. She was frail, and her creatinine was elevated slightly, so NSAIDs were not an option. After much deliberation, I told her that I thought physical therapy was the best option.

"I’ve been going to therapy twice a week for the last month, and it hasn’t helped." The problem just kept getting longer and longer like one of those silk scarves that stage magicians pull out of their hat. "Would you make up your mind," I thought to myself with some irritation, but I remained composed and I reminded myself that it would be unseemly for me to act petulantly with an elderly patient.

After one last round of mental effort, I told her that I would put her on prednisone for a few days. If that didn’t work, I told her I could refer her to an orthopedist, although I knew the orthopedist would be reluctant to suggest surgery for her bursitis and would be left with the same paltry treatment options that I had at my disposal.

I felt relieved when she finally toddled out of the office pleased with my sagacious advice and treatment. My relief was interrupted that afternoon by a phone call from the pharmacy. According to their records, my patient was allergic to prednisone. They didn’t have any details about this allergy, and the patient couldn’t remember anything about it either. Problems concerning this woman kept popping up, despite my best attempts to escape to the next patient. I rummaged through her old chart and told the pharmacy to dispense the medication. She had been on prednisone in 2005 without any problem. Mother had warned me there would be days like this. Medicine is more art than science, and that art calls for finesse, negotiation, and lots of patience.

Medicine would love to be an exact science, but the science of patients can never be exact, as you will see from this small tale of an 81-year-old woman. As a medical student, I always feared presenting patients like her on rounds. When a patient keeps changing key details of the history, it makes the student look like an incompetent idiot in front of the entire team. The professor gets upset and may even demote the trainee to the remedial medical unit.

This woman came to see me because her left hip was hurting. I asked her how long her hip had been hurting, and she told me that it was more than 2 weeks. I examined her and found good range of motion in her hip, but tenderness over the side of her hip, consistent with trochanteric bursitis.

While I was pondering what to do for her painful hip, she mentioned that her family doctor had injected it with cortisone 3 weeks ago, but the injection had not helped. I am not fond of injecting hips, and this absolved me of trying that remedy. This procedure requires a long needle, and a strong determination, but the results are frequently disappointing.

Although I didn’t have to inject her hip, I would have to do something, so I studied her chart more carefully. She was frail, and her creatinine was elevated slightly, so NSAIDs were not an option. After much deliberation, I told her that I thought physical therapy was the best option.

"I’ve been going to therapy twice a week for the last month, and it hasn’t helped." The problem just kept getting longer and longer like one of those silk scarves that stage magicians pull out of their hat. "Would you make up your mind," I thought to myself with some irritation, but I remained composed and I reminded myself that it would be unseemly for me to act petulantly with an elderly patient.

After one last round of mental effort, I told her that I would put her on prednisone for a few days. If that didn’t work, I told her I could refer her to an orthopedist, although I knew the orthopedist would be reluctant to suggest surgery for her bursitis and would be left with the same paltry treatment options that I had at my disposal.

I felt relieved when she finally toddled out of the office pleased with my sagacious advice and treatment. My relief was interrupted that afternoon by a phone call from the pharmacy. According to their records, my patient was allergic to prednisone. They didn’t have any details about this allergy, and the patient couldn’t remember anything about it either. Problems concerning this woman kept popping up, despite my best attempts to escape to the next patient. I rummaged through her old chart and told the pharmacy to dispense the medication. She had been on prednisone in 2005 without any problem. Mother had warned me there would be days like this. Medicine is more art than science, and that art calls for finesse, negotiation, and lots of patience.

Medicine would love to be an exact science, but the science of patients can never be exact, as you will see from this small tale of an 81-year-old woman. As a medical student, I always feared presenting patients like her on rounds. When a patient keeps changing key details of the history, it makes the student look like an incompetent idiot in front of the entire team. The professor gets upset and may even demote the trainee to the remedial medical unit.

This woman came to see me because her left hip was hurting. I asked her how long her hip had been hurting, and she told me that it was more than 2 weeks. I examined her and found good range of motion in her hip, but tenderness over the side of her hip, consistent with trochanteric bursitis.

While I was pondering what to do for her painful hip, she mentioned that her family doctor had injected it with cortisone 3 weeks ago, but the injection had not helped. I am not fond of injecting hips, and this absolved me of trying that remedy. This procedure requires a long needle, and a strong determination, but the results are frequently disappointing.

Although I didn’t have to inject her hip, I would have to do something, so I studied her chart more carefully. She was frail, and her creatinine was elevated slightly, so NSAIDs were not an option. After much deliberation, I told her that I thought physical therapy was the best option.

"I’ve been going to therapy twice a week for the last month, and it hasn’t helped." The problem just kept getting longer and longer like one of those silk scarves that stage magicians pull out of their hat. "Would you make up your mind," I thought to myself with some irritation, but I remained composed and I reminded myself that it would be unseemly for me to act petulantly with an elderly patient.

After one last round of mental effort, I told her that I would put her on prednisone for a few days. If that didn’t work, I told her I could refer her to an orthopedist, although I knew the orthopedist would be reluctant to suggest surgery for her bursitis and would be left with the same paltry treatment options that I had at my disposal.

I felt relieved when she finally toddled out of the office pleased with my sagacious advice and treatment. My relief was interrupted that afternoon by a phone call from the pharmacy. According to their records, my patient was allergic to prednisone. They didn’t have any details about this allergy, and the patient couldn’t remember anything about it either. Problems concerning this woman kept popping up, despite my best attempts to escape to the next patient. I rummaged through her old chart and told the pharmacy to dispense the medication. She had been on prednisone in 2005 without any problem. Mother had warned me there would be days like this. Medicine is more art than science, and that art calls for finesse, negotiation, and lots of patience.

The insanely wasteful American health care system spends a ton of money on a multitiered system. A large percentage of the population is either underinsured or uninsured, while patients in the higher tiers suffer from a surplus of specialists. All too frequently, these poor souls end up with a different specialist for every organ of the body, leading to fragmented care that is very expensive.

Our political leadership struggled ineffectively for decades to understand the root causes of this sorry situation, until someone in Washington finally realized that the key to fixing the health care debacle is primary care. Well, duh!

This brainstorm in the nation’s capital led to a recent explosion of paperwork in my office, and that caught my attention. I was wondering which genius I should thank for this, and lo and behold, it’s the federal government. After doing some cursory online research (that means I cursed and muttered under my breath while I googled my way to the answers I needed) I discovered that the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes Medicare to give extra money to "eligible providers" who become "meaningful users" of electronic health records (EHRs). Instantly, the term "meaningful use" rubbed me the wrong way. The term implies that whatever we were doing before this legislative masterpiece wasn’t meaningful, and might not be the ticket to get on the Medicare gravy train.

My office started trying to establish our bona fides as meaningful users in 2011 with e-prescribing, which is another aspect of meaningful use.

The year 2012 brought about a comically exaggerated resurgence of the new patient health questionnaire. This detailed document requires patients to fill out their social history, allergies, medication list, past hospital admissions, surgeries, family history, and a long review of systems. Before we had to document our high quality as physicians, we used to give this very detailed three-page questionnaire to each new patient, but the federal government, in its infinite wisdom, decided the old way of history taking wasn’t meaningful enough. To show our dedication to meaningful history taking, and the extra reimbursement it entails, we expanded our questionnaire into a bloated four-page document, and each year we make patients fill out a new one. These days, most of my patients have clipboards thick with forms.

In addition to the four-page health questionnaire, my office also gives patients another two-page form to update their insurance and contact information, and patients with rheumatoid arthritis fill out the two-page MD-HAQ (Multidisciplinary Health Assessment Questionnaire). That’s eight pages just to see me for an office follow-up visit scheduled for 15 minutes.

Passing out piles of paper to patients is a relatively easy task for the staff, but practically all my patients have been grumbling about all the forms, and many patients have been unwilling or unable to comply with this new documentation burden. Were I to tell my patients, as they slave over their clipboards, that "this extra paperwork makes me a meaningful user, and allows me to eke out a few more dollars from Medicare," I doubt that my patients would consider this a meaningful use of their time. Keeping patient records up to date is great, but there has to be a better way of doing it.

When I see a patient whom I haven’t seen in a long time, I frequently ask, "Have you had any surgery since last I saw you?" It isn’t necessary for patients to reiterate their entire surgical history. If a patient tells me, "I had my knee replaced recently," that’s important information. If the patient describes their appendectomy in 1932, that certainly has nostalgic value, but is irrelevant to the issues at hand. At least one patient complained "I’m in my 70s and I can’t remember all of this." Many times, family members help the patient wade through all the questions. This sometimes creates interesting synergies. I entered an exam room and found a daughter reading the questions out loud to help her mother. "Mom, have you ever had breast implants?"

The most important part of the four-page health questionnaire is the signature line on the last page. If I fail to sign my name, I will be visited later in the afternoon by the signature clerk, helping to keep me meaningful. I’ve gotten wise to this pitfall, so normally I am careful to scribble my name on the bottom line as soon as I enter the room. After that signature, I also sign the patient’s superbill, the MD-HAQ, as well as any lab orders, FMLA (Family and Medical Leave Act) forms, or written prescriptions that need my signature. This morning I told one patient, "I have to sign my name three times before I can sit down." I told another elderly patient that I would try and squeeze her in between the many forms I had to fill out in her 15-minute visit. Many trees are needed to keep the questionnaires coming. This is the burden of meaningful use.

Are all questions necessary for all patients, or should the history be focused? As medical students, we were taught to do a detailed physical exam. That’s appropriate sometimes, especially if medical school graduation depends on it, but sooner or later we all learn that brevity is needed for survival. Some parts of the exam are critical, while others are expendable. For example, checking ear drums is very important for evaluating an earache, but useless for evaluating hemorrhoids.

By mindlessly passing out forms to every patient, we are not tailoring our approach to each patient, but adopting a "one-size-fits-all" approach for the practice of medicine. Maybe I’m just old fashioned and out of touch, but is it really necessary to request great-grandparents and members of the clergy to disclose information about their sexual orientation and practices? Perhaps these data will make our electronic records slightly less boring for hackers, although the hackers may be disappointed to find that many patients skip such sensitive questions. That doesn’t bother me at all, as patients have their own definition of meaningful use, but I hope the federal government will not subtract any of my brownie points.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

The insanely wasteful American health care system spends a ton of money on a multitiered system. A large percentage of the population is either underinsured or uninsured, while patients in the higher tiers suffer from a surplus of specialists. All too frequently, these poor souls end up with a different specialist for every organ of the body, leading to fragmented care that is very expensive.

Our political leadership struggled ineffectively for decades to understand the root causes of this sorry situation, until someone in Washington finally realized that the key to fixing the health care debacle is primary care. Well, duh!

This brainstorm in the nation’s capital led to a recent explosion of paperwork in my office, and that caught my attention. I was wondering which genius I should thank for this, and lo and behold, it’s the federal government. After doing some cursory online research (that means I cursed and muttered under my breath while I googled my way to the answers I needed) I discovered that the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes Medicare to give extra money to "eligible providers" who become "meaningful users" of electronic health records (EHRs). Instantly, the term "meaningful use" rubbed me the wrong way. The term implies that whatever we were doing before this legislative masterpiece wasn’t meaningful, and might not be the ticket to get on the Medicare gravy train.

My office started trying to establish our bona fides as meaningful users in 2011 with e-prescribing, which is another aspect of meaningful use.

The year 2012 brought about a comically exaggerated resurgence of the new patient health questionnaire. This detailed document requires patients to fill out their social history, allergies, medication list, past hospital admissions, surgeries, family history, and a long review of systems. Before we had to document our high quality as physicians, we used to give this very detailed three-page questionnaire to each new patient, but the federal government, in its infinite wisdom, decided the old way of history taking wasn’t meaningful enough. To show our dedication to meaningful history taking, and the extra reimbursement it entails, we expanded our questionnaire into a bloated four-page document, and each year we make patients fill out a new one. These days, most of my patients have clipboards thick with forms.

In addition to the four-page health questionnaire, my office also gives patients another two-page form to update their insurance and contact information, and patients with rheumatoid arthritis fill out the two-page MD-HAQ (Multidisciplinary Health Assessment Questionnaire). That’s eight pages just to see me for an office follow-up visit scheduled for 15 minutes.

Passing out piles of paper to patients is a relatively easy task for the staff, but practically all my patients have been grumbling about all the forms, and many patients have been unwilling or unable to comply with this new documentation burden. Were I to tell my patients, as they slave over their clipboards, that "this extra paperwork makes me a meaningful user, and allows me to eke out a few more dollars from Medicare," I doubt that my patients would consider this a meaningful use of their time. Keeping patient records up to date is great, but there has to be a better way of doing it.

When I see a patient whom I haven’t seen in a long time, I frequently ask, "Have you had any surgery since last I saw you?" It isn’t necessary for patients to reiterate their entire surgical history. If a patient tells me, "I had my knee replaced recently," that’s important information. If the patient describes their appendectomy in 1932, that certainly has nostalgic value, but is irrelevant to the issues at hand. At least one patient complained "I’m in my 70s and I can’t remember all of this." Many times, family members help the patient wade through all the questions. This sometimes creates interesting synergies. I entered an exam room and found a daughter reading the questions out loud to help her mother. "Mom, have you ever had breast implants?"

The most important part of the four-page health questionnaire is the signature line on the last page. If I fail to sign my name, I will be visited later in the afternoon by the signature clerk, helping to keep me meaningful. I’ve gotten wise to this pitfall, so normally I am careful to scribble my name on the bottom line as soon as I enter the room. After that signature, I also sign the patient’s superbill, the MD-HAQ, as well as any lab orders, FMLA (Family and Medical Leave Act) forms, or written prescriptions that need my signature. This morning I told one patient, "I have to sign my name three times before I can sit down." I told another elderly patient that I would try and squeeze her in between the many forms I had to fill out in her 15-minute visit. Many trees are needed to keep the questionnaires coming. This is the burden of meaningful use.

Are all questions necessary for all patients, or should the history be focused? As medical students, we were taught to do a detailed physical exam. That’s appropriate sometimes, especially if medical school graduation depends on it, but sooner or later we all learn that brevity is needed for survival. Some parts of the exam are critical, while others are expendable. For example, checking ear drums is very important for evaluating an earache, but useless for evaluating hemorrhoids.

By mindlessly passing out forms to every patient, we are not tailoring our approach to each patient, but adopting a "one-size-fits-all" approach for the practice of medicine. Maybe I’m just old fashioned and out of touch, but is it really necessary to request great-grandparents and members of the clergy to disclose information about their sexual orientation and practices? Perhaps these data will make our electronic records slightly less boring for hackers, although the hackers may be disappointed to find that many patients skip such sensitive questions. That doesn’t bother me at all, as patients have their own definition of meaningful use, but I hope the federal government will not subtract any of my brownie points.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

The insanely wasteful American health care system spends a ton of money on a multitiered system. A large percentage of the population is either underinsured or uninsured, while patients in the higher tiers suffer from a surplus of specialists. All too frequently, these poor souls end up with a different specialist for every organ of the body, leading to fragmented care that is very expensive.

Our political leadership struggled ineffectively for decades to understand the root causes of this sorry situation, until someone in Washington finally realized that the key to fixing the health care debacle is primary care. Well, duh!

This brainstorm in the nation’s capital led to a recent explosion of paperwork in my office, and that caught my attention. I was wondering which genius I should thank for this, and lo and behold, it’s the federal government. After doing some cursory online research (that means I cursed and muttered under my breath while I googled my way to the answers I needed) I discovered that the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes Medicare to give extra money to "eligible providers" who become "meaningful users" of electronic health records (EHRs). Instantly, the term "meaningful use" rubbed me the wrong way. The term implies that whatever we were doing before this legislative masterpiece wasn’t meaningful, and might not be the ticket to get on the Medicare gravy train.

My office started trying to establish our bona fides as meaningful users in 2011 with e-prescribing, which is another aspect of meaningful use.

The year 2012 brought about a comically exaggerated resurgence of the new patient health questionnaire. This detailed document requires patients to fill out their social history, allergies, medication list, past hospital admissions, surgeries, family history, and a long review of systems. Before we had to document our high quality as physicians, we used to give this very detailed three-page questionnaire to each new patient, but the federal government, in its infinite wisdom, decided the old way of history taking wasn’t meaningful enough. To show our dedication to meaningful history taking, and the extra reimbursement it entails, we expanded our questionnaire into a bloated four-page document, and each year we make patients fill out a new one. These days, most of my patients have clipboards thick with forms.

In addition to the four-page health questionnaire, my office also gives patients another two-page form to update their insurance and contact information, and patients with rheumatoid arthritis fill out the two-page MD-HAQ (Multidisciplinary Health Assessment Questionnaire). That’s eight pages just to see me for an office follow-up visit scheduled for 15 minutes.

Passing out piles of paper to patients is a relatively easy task for the staff, but practically all my patients have been grumbling about all the forms, and many patients have been unwilling or unable to comply with this new documentation burden. Were I to tell my patients, as they slave over their clipboards, that "this extra paperwork makes me a meaningful user, and allows me to eke out a few more dollars from Medicare," I doubt that my patients would consider this a meaningful use of their time. Keeping patient records up to date is great, but there has to be a better way of doing it.

When I see a patient whom I haven’t seen in a long time, I frequently ask, "Have you had any surgery since last I saw you?" It isn’t necessary for patients to reiterate their entire surgical history. If a patient tells me, "I had my knee replaced recently," that’s important information. If the patient describes their appendectomy in 1932, that certainly has nostalgic value, but is irrelevant to the issues at hand. At least one patient complained "I’m in my 70s and I can’t remember all of this." Many times, family members help the patient wade through all the questions. This sometimes creates interesting synergies. I entered an exam room and found a daughter reading the questions out loud to help her mother. "Mom, have you ever had breast implants?"

The most important part of the four-page health questionnaire is the signature line on the last page. If I fail to sign my name, I will be visited later in the afternoon by the signature clerk, helping to keep me meaningful. I’ve gotten wise to this pitfall, so normally I am careful to scribble my name on the bottom line as soon as I enter the room. After that signature, I also sign the patient’s superbill, the MD-HAQ, as well as any lab orders, FMLA (Family and Medical Leave Act) forms, or written prescriptions that need my signature. This morning I told one patient, "I have to sign my name three times before I can sit down." I told another elderly patient that I would try and squeeze her in between the many forms I had to fill out in her 15-minute visit. Many trees are needed to keep the questionnaires coming. This is the burden of meaningful use.

Are all questions necessary for all patients, or should the history be focused? As medical students, we were taught to do a detailed physical exam. That’s appropriate sometimes, especially if medical school graduation depends on it, but sooner or later we all learn that brevity is needed for survival. Some parts of the exam are critical, while others are expendable. For example, checking ear drums is very important for evaluating an earache, but useless for evaluating hemorrhoids.

By mindlessly passing out forms to every patient, we are not tailoring our approach to each patient, but adopting a "one-size-fits-all" approach for the practice of medicine. Maybe I’m just old fashioned and out of touch, but is it really necessary to request great-grandparents and members of the clergy to disclose information about their sexual orientation and practices? Perhaps these data will make our electronic records slightly less boring for hackers, although the hackers may be disappointed to find that many patients skip such sensitive questions. That doesn’t bother me at all, as patients have their own definition of meaningful use, but I hope the federal government will not subtract any of my brownie points.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

One of my patients with rheumatoid arthritis had been doing quite well on methotrexate 15 mg/week.

About a year ago he told me that his pharmacy had switched him from the Barr generic methotrexate (MTX) to Roxane generic MTX. About 2 months later, he started having increased pain in his hands, wrists, and shoulders. By the time he came back to see me a few months later, he was quite unhappy with his pharmacy, and he was also convinced that his new generic was not the therapeutic equivalent of his previous generic.

I sympathized with him and shared my conventional wisdom regarding the mixed blessings of generic medications: "You save money," I reminded him, "but once the doctor signs on the ‘may substitute’ side of the prescription, the doctor and patient lose control over which generic the pharmacy chooses to fill the prescription." Usually the pharmacy chooses the least expensive generic. I gave him some lame advice to speak with the pharmacist about getting back on the original generic, or perhaps changing to a different pharmacy to get a different generic.

He came back about 6 months later feeling better. He had changed pharmacies and was now using Mylan generic MTX. I didn’t have objective physical exam or lab findings to confirm that his arthritis had truly flared up during the time he was on Roxane generic MTX, but he was certainly convinced that the pharmacy had given him a dud. The perception is the reality in situations like this – that is, he certainly felt worse – and I didn’t have objective evidence to refute his opinion, or any strong interest in arguing.

I think this is an intriguing anecdote, as the vast majority of patients on MTX are using generics. I’m sure the number of patients in my practice taking brand-name MTX can be counted on one hand. In fact, most of my patients prefer generic medications – many ask if the medication I am prescribing is "genetic" – because it’s much cheaper for them. In a better world, we should be able to prescribe generic medications but also retain some control over which generic is dispensed. Is that too much to ask?

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

One of my patients with rheumatoid arthritis had been doing quite well on methotrexate 15 mg/week.

About a year ago he told me that his pharmacy had switched him from the Barr generic methotrexate (MTX) to Roxane generic MTX. About 2 months later, he started having increased pain in his hands, wrists, and shoulders. By the time he came back to see me a few months later, he was quite unhappy with his pharmacy, and he was also convinced that his new generic was not the therapeutic equivalent of his previous generic.

I sympathized with him and shared my conventional wisdom regarding the mixed blessings of generic medications: "You save money," I reminded him, "but once the doctor signs on the ‘may substitute’ side of the prescription, the doctor and patient lose control over which generic the pharmacy chooses to fill the prescription." Usually the pharmacy chooses the least expensive generic. I gave him some lame advice to speak with the pharmacist about getting back on the original generic, or perhaps changing to a different pharmacy to get a different generic.

He came back about 6 months later feeling better. He had changed pharmacies and was now using Mylan generic MTX. I didn’t have objective physical exam or lab findings to confirm that his arthritis had truly flared up during the time he was on Roxane generic MTX, but he was certainly convinced that the pharmacy had given him a dud. The perception is the reality in situations like this – that is, he certainly felt worse – and I didn’t have objective evidence to refute his opinion, or any strong interest in arguing.

I think this is an intriguing anecdote, as the vast majority of patients on MTX are using generics. I’m sure the number of patients in my practice taking brand-name MTX can be counted on one hand. In fact, most of my patients prefer generic medications – many ask if the medication I am prescribing is "genetic" – because it’s much cheaper for them. In a better world, we should be able to prescribe generic medications but also retain some control over which generic is dispensed. Is that too much to ask?

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

One of my patients with rheumatoid arthritis had been doing quite well on methotrexate 15 mg/week.

About a year ago he told me that his pharmacy had switched him from the Barr generic methotrexate (MTX) to Roxane generic MTX. About 2 months later, he started having increased pain in his hands, wrists, and shoulders. By the time he came back to see me a few months later, he was quite unhappy with his pharmacy, and he was also convinced that his new generic was not the therapeutic equivalent of his previous generic.

I sympathized with him and shared my conventional wisdom regarding the mixed blessings of generic medications: "You save money," I reminded him, "but once the doctor signs on the ‘may substitute’ side of the prescription, the doctor and patient lose control over which generic the pharmacy chooses to fill the prescription." Usually the pharmacy chooses the least expensive generic. I gave him some lame advice to speak with the pharmacist about getting back on the original generic, or perhaps changing to a different pharmacy to get a different generic.

He came back about 6 months later feeling better. He had changed pharmacies and was now using Mylan generic MTX. I didn’t have objective physical exam or lab findings to confirm that his arthritis had truly flared up during the time he was on Roxane generic MTX, but he was certainly convinced that the pharmacy had given him a dud. The perception is the reality in situations like this – that is, he certainly felt worse – and I didn’t have objective evidence to refute his opinion, or any strong interest in arguing.

I think this is an intriguing anecdote, as the vast majority of patients on MTX are using generics. I’m sure the number of patients in my practice taking brand-name MTX can be counted on one hand. In fact, most of my patients prefer generic medications – many ask if the medication I am prescribing is "genetic" – because it’s much cheaper for them. In a better world, we should be able to prescribe generic medications but also retain some control over which generic is dispensed. Is that too much to ask?

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

We all learn about the importance of a good history and physical in medical school, but to really understand what makes a patient tick, you have to be curious about the patient’s life outside the office. Patient tattoos have always interested me, and this sometimes leads to unexpected discoveries. It’s hard to explain what makes one tattoo interesting, while another one is ho-hum. I’ve seen plenty of older men, (that is, anyone older than me) with naked women tattooed on their arms. Presumably these tattoos are souvenirs of their wild youth. I don’t ask about these, but I can’t help but wonder how they would reply should their grandchildren ask them about these racy images.

zimmytws/fotolia.com

For a while, it was fashionable to have "love" inscribed on the knuckles of one hand and "hate" on the other hand. I’ve had a few patients with these tattoos, but the most memorable was a patient that everyone said looked like Charles Manson. He was probably harmless, but people didn’t spend any more time with him than they had to, and I doubt anyone asked him about his tattoos.

One of my less sinister looking patients has a Celtic cross of protection on his right upper arm. I asked him about it once, and he told me he used to be a cop. He felt more secure with this image permanently on his arm. I’ve seen a number of biblical verses too, some of them positioned in less than modest places on the physique. I wonder if it is still called a "tramp stamp" if it comes from the good book?

Some patients have fearsome looking tattoos, but they are very insecure people. Among my patients is one large muscular man with huge tigers on his arms who looks like the kind of fellow you would not want to meet in a dark alley. He recounted vividly the story of his first cardiac catheterization. He was on the table when he spied the cardiologist bringing over a tray of instruments. He sat bolt upright to flee, but someone held him down, and he got an extra shot of diazepam. The person holding him down must have been pretty big too.

Flowers and butterflies are generally passé, but foreign language tattoos are interesting. Oriental calligraphy can be lovely, but Hebrew can be tricky. I’ve seen a few tattoos that had problems because either the tattoo artist, or the tattoo recipient, or both, didn’t know that Hebrew goes from right to left, creating an unintentional tattoo dyslexia. It’s not written in stone, but correcting a typo written on flesh is almost as difficult.

Another one of my patients has a picture of a heart pierced by a dagger dripping blood. I made some benign comment about this frightful image. He told me that this was a Mafioso tattoo, and he assured me that it was "real." He seemed rather pleased explaining this to me, and I didn’t ask for any documentation of his right to sport this symbol.

He used to consider me a miracle worker because his arthritis improved so nicely with methotrexate and prednisone. He often embarrassed me by referring to me as "Dr. God." In general he was polite to the point of being deferential. We got along quite well, but there were some notable exceptions.

His wife, a middle-aged smoker, was also my patient. The Mafioso called the office one day and demanded that his wife be seen right away because she was short of breath. My schedule was full and the nurse offered her an appointment with a nurse practitioner. He became increasingly loud and nasty, yelling at the nurse. He was on the phone because his wife was too short of breath to speak in full sentences. The husband informed my nurse that he was bringing his wife to our office for immediate attention. He told the nurse he’d take his wife to the hospital ER across the street if she didn’t get immediate attention

As providence had arranged things, Dr. God had a convenient cancelation at the same time the don and his gasping wife arrived. After I took one look at his wife, I wished he had taken her to the ER. She was gray, dyspneic, weak, and quite drowsy. She had lost 25 pounds since I last saw her, and her husband informed me that she still smoked two packs a day. I was worried about congestive heart failure, pulmonary embolus, and stroke, but quickly decided this was most likely emphysema. I was concerned that she might have a respiratory arrest while I was going about the bureaucratic admission process.

"I’ve been in business for 25 years and I know when I’m not being treated right," her husband stormed in the background. My patient didn’t like the way his phone calls had been fielded. I wondered if the mafia has customer service representatives. Do they put you on hold and make you listen to recorded messages? "All of our assassins are assisting other callers. Your call is very important to us, please stay on the line." He thought that his wife’s condition should guarantee her immediate care. I tried to explain that our office was ill equipped to deal with acute emergencies. In a convoluted way it was a compliment that he thought Dr. God’s office was the best place to bring his breathless wife, but in reality, it was just pig-headed and stupid. He didn’t buy my arguments. He warned me that I didn’t want to see him lose his temper, and he reminded me about his tattoo.

He didn’t mention it, but I recalled that I once had him take his boots off, so I could check his arthritic feet. Something shiny in the bottom of his boot caught my eye. I thought he had metal orthotics in his shoes, but he corrected me politely, and told me that the shiny object was a gun. I thought it might be quite impractical to make a fast draw for a gun concealed in the bottom of a tall boot, but what do I know about guns? I’m a good little rheumatologist, and always very curious, but I wouldn’t want that to be my epithet, so I stifled my curiosity, and I didn’t ask for a demonstration.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

We all learn about the importance of a good history and physical in medical school, but to really understand what makes a patient tick, you have to be curious about the patient’s life outside the office. Patient tattoos have always interested me, and this sometimes leads to unexpected discoveries. It’s hard to explain what makes one tattoo interesting, while another one is ho-hum. I’ve seen plenty of older men, (that is, anyone older than me) with naked women tattooed on their arms. Presumably these tattoos are souvenirs of their wild youth. I don’t ask about these, but I can’t help but wonder how they would reply should their grandchildren ask them about these racy images.

zimmytws/fotolia.com

For a while, it was fashionable to have "love" inscribed on the knuckles of one hand and "hate" on the other hand. I’ve had a few patients with these tattoos, but the most memorable was a patient that everyone said looked like Charles Manson. He was probably harmless, but people didn’t spend any more time with him than they had to, and I doubt anyone asked him about his tattoos.

One of my less sinister looking patients has a Celtic cross of protection on his right upper arm. I asked him about it once, and he told me he used to be a cop. He felt more secure with this image permanently on his arm. I’ve seen a number of biblical verses too, some of them positioned in less than modest places on the physique. I wonder if it is still called a "tramp stamp" if it comes from the good book?

Some patients have fearsome looking tattoos, but they are very insecure people. Among my patients is one large muscular man with huge tigers on his arms who looks like the kind of fellow you would not want to meet in a dark alley. He recounted vividly the story of his first cardiac catheterization. He was on the table when he spied the cardiologist bringing over a tray of instruments. He sat bolt upright to flee, but someone held him down, and he got an extra shot of diazepam. The person holding him down must have been pretty big too.

Flowers and butterflies are generally passé, but foreign language tattoos are interesting. Oriental calligraphy can be lovely, but Hebrew can be tricky. I’ve seen a few tattoos that had problems because either the tattoo artist, or the tattoo recipient, or both, didn’t know that Hebrew goes from right to left, creating an unintentional tattoo dyslexia. It’s not written in stone, but correcting a typo written on flesh is almost as difficult.

Another one of my patients has a picture of a heart pierced by a dagger dripping blood. I made some benign comment about this frightful image. He told me that this was a Mafioso tattoo, and he assured me that it was "real." He seemed rather pleased explaining this to me, and I didn’t ask for any documentation of his right to sport this symbol.

He used to consider me a miracle worker because his arthritis improved so nicely with methotrexate and prednisone. He often embarrassed me by referring to me as "Dr. God." In general he was polite to the point of being deferential. We got along quite well, but there were some notable exceptions.

His wife, a middle-aged smoker, was also my patient. The Mafioso called the office one day and demanded that his wife be seen right away because she was short of breath. My schedule was full and the nurse offered her an appointment with a nurse practitioner. He became increasingly loud and nasty, yelling at the nurse. He was on the phone because his wife was too short of breath to speak in full sentences. The husband informed my nurse that he was bringing his wife to our office for immediate attention. He told the nurse he’d take his wife to the hospital ER across the street if she didn’t get immediate attention

As providence had arranged things, Dr. God had a convenient cancelation at the same time the don and his gasping wife arrived. After I took one look at his wife, I wished he had taken her to the ER. She was gray, dyspneic, weak, and quite drowsy. She had lost 25 pounds since I last saw her, and her husband informed me that she still smoked two packs a day. I was worried about congestive heart failure, pulmonary embolus, and stroke, but quickly decided this was most likely emphysema. I was concerned that she might have a respiratory arrest while I was going about the bureaucratic admission process.

"I’ve been in business for 25 years and I know when I’m not being treated right," her husband stormed in the background. My patient didn’t like the way his phone calls had been fielded. I wondered if the mafia has customer service representatives. Do they put you on hold and make you listen to recorded messages? "All of our assassins are assisting other callers. Your call is very important to us, please stay on the line." He thought that his wife’s condition should guarantee her immediate care. I tried to explain that our office was ill equipped to deal with acute emergencies. In a convoluted way it was a compliment that he thought Dr. God’s office was the best place to bring his breathless wife, but in reality, it was just pig-headed and stupid. He didn’t buy my arguments. He warned me that I didn’t want to see him lose his temper, and he reminded me about his tattoo.

He didn’t mention it, but I recalled that I once had him take his boots off, so I could check his arthritic feet. Something shiny in the bottom of his boot caught my eye. I thought he had metal orthotics in his shoes, but he corrected me politely, and told me that the shiny object was a gun. I thought it might be quite impractical to make a fast draw for a gun concealed in the bottom of a tall boot, but what do I know about guns? I’m a good little rheumatologist, and always very curious, but I wouldn’t want that to be my epithet, so I stifled my curiosity, and I didn’t ask for a demonstration.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

We all learn about the importance of a good history and physical in medical school, but to really understand what makes a patient tick, you have to be curious about the patient’s life outside the office. Patient tattoos have always interested me, and this sometimes leads to unexpected discoveries. It’s hard to explain what makes one tattoo interesting, while another one is ho-hum. I’ve seen plenty of older men, (that is, anyone older than me) with naked women tattooed on their arms. Presumably these tattoos are souvenirs of their wild youth. I don’t ask about these, but I can’t help but wonder how they would reply should their grandchildren ask them about these racy images.

zimmytws/fotolia.com

For a while, it was fashionable to have "love" inscribed on the knuckles of one hand and "hate" on the other hand. I’ve had a few patients with these tattoos, but the most memorable was a patient that everyone said looked like Charles Manson. He was probably harmless, but people didn’t spend any more time with him than they had to, and I doubt anyone asked him about his tattoos.

One of my less sinister looking patients has a Celtic cross of protection on his right upper arm. I asked him about it once, and he told me he used to be a cop. He felt more secure with this image permanently on his arm. I’ve seen a number of biblical verses too, some of them positioned in less than modest places on the physique. I wonder if it is still called a "tramp stamp" if it comes from the good book?

Some patients have fearsome looking tattoos, but they are very insecure people. Among my patients is one large muscular man with huge tigers on his arms who looks like the kind of fellow you would not want to meet in a dark alley. He recounted vividly the story of his first cardiac catheterization. He was on the table when he spied the cardiologist bringing over a tray of instruments. He sat bolt upright to flee, but someone held him down, and he got an extra shot of diazepam. The person holding him down must have been pretty big too.

Flowers and butterflies are generally passé, but foreign language tattoos are interesting. Oriental calligraphy can be lovely, but Hebrew can be tricky. I’ve seen a few tattoos that had problems because either the tattoo artist, or the tattoo recipient, or both, didn’t know that Hebrew goes from right to left, creating an unintentional tattoo dyslexia. It’s not written in stone, but correcting a typo written on flesh is almost as difficult.

Another one of my patients has a picture of a heart pierced by a dagger dripping blood. I made some benign comment about this frightful image. He told me that this was a Mafioso tattoo, and he assured me that it was "real." He seemed rather pleased explaining this to me, and I didn’t ask for any documentation of his right to sport this symbol.

He used to consider me a miracle worker because his arthritis improved so nicely with methotrexate and prednisone. He often embarrassed me by referring to me as "Dr. God." In general he was polite to the point of being deferential. We got along quite well, but there were some notable exceptions.

His wife, a middle-aged smoker, was also my patient. The Mafioso called the office one day and demanded that his wife be seen right away because she was short of breath. My schedule was full and the nurse offered her an appointment with a nurse practitioner. He became increasingly loud and nasty, yelling at the nurse. He was on the phone because his wife was too short of breath to speak in full sentences. The husband informed my nurse that he was bringing his wife to our office for immediate attention. He told the nurse he’d take his wife to the hospital ER across the street if she didn’t get immediate attention

As providence had arranged things, Dr. God had a convenient cancelation at the same time the don and his gasping wife arrived. After I took one look at his wife, I wished he had taken her to the ER. She was gray, dyspneic, weak, and quite drowsy. She had lost 25 pounds since I last saw her, and her husband informed me that she still smoked two packs a day. I was worried about congestive heart failure, pulmonary embolus, and stroke, but quickly decided this was most likely emphysema. I was concerned that she might have a respiratory arrest while I was going about the bureaucratic admission process.

"I’ve been in business for 25 years and I know when I’m not being treated right," her husband stormed in the background. My patient didn’t like the way his phone calls had been fielded. I wondered if the mafia has customer service representatives. Do they put you on hold and make you listen to recorded messages? "All of our assassins are assisting other callers. Your call is very important to us, please stay on the line." He thought that his wife’s condition should guarantee her immediate care. I tried to explain that our office was ill equipped to deal with acute emergencies. In a convoluted way it was a compliment that he thought Dr. God’s office was the best place to bring his breathless wife, but in reality, it was just pig-headed and stupid. He didn’t buy my arguments. He warned me that I didn’t want to see him lose his temper, and he reminded me about his tattoo.

He didn’t mention it, but I recalled that I once had him take his boots off, so I could check his arthritic feet. Something shiny in the bottom of his boot caught my eye. I thought he had metal orthotics in his shoes, but he corrected me politely, and told me that the shiny object was a gun. I thought it might be quite impractical to make a fast draw for a gun concealed in the bottom of a tall boot, but what do I know about guns? I’m a good little rheumatologist, and always very curious, but I wouldn’t want that to be my epithet, so I stifled my curiosity, and I didn’t ask for a demonstration.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Complaints that patients need to be seen sooner than the schedule can accommodate are a reliable vital sign that a practice is busy enough. When this situation arises in my practice, the nurse usually leaves me a pile of records from the referring physician, and a note explaining why the patient needs to be seen as soon as possible. In a case where the note includes the word fibromyalgia, that pile of records moves to the bottom of the stack.

A recent note regarding a patient with gout made its way to my desk. The referring physician was from a very large and respected cardiology group, and I knew with certainty that the physicians in this group prided themselves on never considering any body part south of the diaphragm. A short note said that the patient had gout and needed to be seen as soon as possible. This struck a humanitarian cord within me. Gout is really painful, and the thought of some elderly patient with podagra due to the cardiologist’s massive administration of furosemide made me think that this is someone that deserved expedited attention.

I had the patient squeezed into my schedule at a time that I don’t usually see new patients and I opened the door expecting to find the usual pitiful scene of a patient with one shoe on and one shoe off, awaiting my words of wisdom and healing, or at least the compassion to not role the wheels of my examining stool over their gouty extremity. What I found was different than my expectation.

The patient had a blue painful toe rather than a red painful toe. As the story unfolded, it turned out that the patient had been to the emergency room a month earlier and had been given futile treatment with antibiotics for possible cellulitis. Later, the patient’s cardiologist did an angiogram of her leg, and she was diagnosed with small vessel peripheral vascular disease. The cardiologist was worried that perhaps she had gout in addition to ischemia. She saw another rheumatologist in the neighborhood who had already told her that she didn’t have gout!

"He didn’t listen to me at all," my distraught patient with the blue toe complained. "He just wanted to talk to me about my smoking and fibromyalgia."

This wasn’t untreated gout. The "emergency" was due to the patient’s dislike for the other rheumatologist. I felt cheated, but I tried to be more likeable than my maligned colleague! I listened to the whole tale of woe and carefully explained that an ischemic blue toe was better than a gangrenous black toe. She gave me a plaintive glare as she hobbled out, but she looked as if she might even stop smoking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Complaints that patients need to be seen sooner than the schedule can accommodate are a reliable vital sign that a practice is busy enough. When this situation arises in my practice, the nurse usually leaves me a pile of records from the referring physician, and a note explaining why the patient needs to be seen as soon as possible. In a case where the note includes the word fibromyalgia, that pile of records moves to the bottom of the stack.

A recent note regarding a patient with gout made its way to my desk. The referring physician was from a very large and respected cardiology group, and I knew with certainty that the physicians in this group prided themselves on never considering any body part south of the diaphragm. A short note said that the patient had gout and needed to be seen as soon as possible. This struck a humanitarian cord within me. Gout is really painful, and the thought of some elderly patient with podagra due to the cardiologist’s massive administration of furosemide made me think that this is someone that deserved expedited attention.

I had the patient squeezed into my schedule at a time that I don’t usually see new patients and I opened the door expecting to find the usual pitiful scene of a patient with one shoe on and one shoe off, awaiting my words of wisdom and healing, or at least the compassion to not role the wheels of my examining stool over their gouty extremity. What I found was different than my expectation.

The patient had a blue painful toe rather than a red painful toe. As the story unfolded, it turned out that the patient had been to the emergency room a month earlier and had been given futile treatment with antibiotics for possible cellulitis. Later, the patient’s cardiologist did an angiogram of her leg, and she was diagnosed with small vessel peripheral vascular disease. The cardiologist was worried that perhaps she had gout in addition to ischemia. She saw another rheumatologist in the neighborhood who had already told her that she didn’t have gout!

"He didn’t listen to me at all," my distraught patient with the blue toe complained. "He just wanted to talk to me about my smoking and fibromyalgia."

This wasn’t untreated gout. The "emergency" was due to the patient’s dislike for the other rheumatologist. I felt cheated, but I tried to be more likeable than my maligned colleague! I listened to the whole tale of woe and carefully explained that an ischemic blue toe was better than a gangrenous black toe. She gave me a plaintive glare as she hobbled out, but she looked as if she might even stop smoking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.

Complaints that patients need to be seen sooner than the schedule can accommodate are a reliable vital sign that a practice is busy enough. When this situation arises in my practice, the nurse usually leaves me a pile of records from the referring physician, and a note explaining why the patient needs to be seen as soon as possible. In a case where the note includes the word fibromyalgia, that pile of records moves to the bottom of the stack.

A recent note regarding a patient with gout made its way to my desk. The referring physician was from a very large and respected cardiology group, and I knew with certainty that the physicians in this group prided themselves on never considering any body part south of the diaphragm. A short note said that the patient had gout and needed to be seen as soon as possible. This struck a humanitarian cord within me. Gout is really painful, and the thought of some elderly patient with podagra due to the cardiologist’s massive administration of furosemide made me think that this is someone that deserved expedited attention.

I had the patient squeezed into my schedule at a time that I don’t usually see new patients and I opened the door expecting to find the usual pitiful scene of a patient with one shoe on and one shoe off, awaiting my words of wisdom and healing, or at least the compassion to not role the wheels of my examining stool over their gouty extremity. What I found was different than my expectation.

The patient had a blue painful toe rather than a red painful toe. As the story unfolded, it turned out that the patient had been to the emergency room a month earlier and had been given futile treatment with antibiotics for possible cellulitis. Later, the patient’s cardiologist did an angiogram of her leg, and she was diagnosed with small vessel peripheral vascular disease. The cardiologist was worried that perhaps she had gout in addition to ischemia. She saw another rheumatologist in the neighborhood who had already told her that she didn’t have gout!

"He didn’t listen to me at all," my distraught patient with the blue toe complained. "He just wanted to talk to me about my smoking and fibromyalgia."

This wasn’t untreated gout. The "emergency" was due to the patient’s dislike for the other rheumatologist. I felt cheated, but I tried to be more likeable than my maligned colleague! I listened to the whole tale of woe and carefully explained that an ischemic blue toe was better than a gangrenous black toe. She gave me a plaintive glare as she hobbled out, but she looked as if she might even stop smoking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.