Larry Greenbaum, MD

Deciding to have patients resume biologic medications after they have had serious infections is one of the toughest decisions I make in practice.

A woman with rheumatoid arthritis developed Escherichia coli septic arthritis of her knee. She survived, but in view of her comorbid conditions, including severe emphysema, I was worried that she might not survive another serious infection and I told her not to go back on etanercept. I tried treating her with various nonbiologic disease modifying drugs that previously had inadequate results: As you might expect, the results were dismal. Her huge swollen joints reminded me of one of my professors with a flair for the dramatic. He would say things in clinic like, "This patient has 2 pounds of synovium in her wrist."

Toward the end, her care was largely palliative and consisted of analgesics and prednisone. Her quality of life was quite diminished because of very severe arthritis. I felt twinges of guilt and helplessness every time I saw her during the last few years of her life.

Another patient on abatacept developed an abscess in his calf. A bit of a curmudgeon, he was quite annoyed that it took the hospital doctors a few days to figure out that he had an abscess after he was originally misdiagnosed with cellulitis. My point of view was exactly the opposite, and I was impressed that the hospital doctors had arrived at the correct diagnosis so quickly.

I tried to explain that cellulitis was a common illness but that calf abscesses were rare. He reluctantly accepted my explanation, or at least he got tired of complaining about it. He is about the same age as the woman I mentioned above, but he is much more robust. Even though he is well into his 70s, he loves to play softball in various senior leagues. He spends his winters in Florida in a kind of perpetual spring training. I was worried about putting him back on his medication, but his overall health was good. If I didn’t put him back on the medication, I knew it would be the end of his softball days, and I’d either lose a patient or, worse yet, have a more-unhappy-than-usual curmudgeon in my office. I have plenty of those already.

A 65-year-old woman with RA in my practice was doing very well on methotrexate and etanercept. She too was hospitalized with septic arthritis of her knee. After she got out of the hospital, she came back to see me. She had already been off etanercept for over a month, her arthritis was getting worse, and she wanted to resume etanercept. I told her not to resume the medication because I thought it was too dangerous. I discussed other options, including adding other nonbiologic medications such as hydroxychloroquine or prednisone, or perhaps a biologic such as rituximab. She didn’t like any of these options and we remained in a standoff, so I asked her to come back in a few months.

She was due back in 2 months but she didn’t come back to the office until 5 months later. When I walked in she told me that she was much better. The nurse had written in the chart, "wants etanercept." I was confused. Why did she want to go back on the medication if her arthritis was doing so well without it? "You’ve been off the etanercept since your septic arthritis, haven’t you? You didn’t resume it, did you?"

She had resumed the medication. My immediate thought was that maybe her family doctor had refilled it for her or, worse yet, I had refilled it inadvertently during a senior moment. Seeing my bewilderment, she reassured me that I wasn’t having a senior moment.

She went on to explain why, for several reasons, she had decided on her own to resume the medication shortly after her previous visit. She had about a 4- month supply of the medication in her refrigerator (probably about $7,000 or $8,000 worth) and she couldn’t bring herself to waste it. Only carefully trained medical professionals can waste money on such a grand scale and not lose any sleep over it. She also assumed that her risk of infection would be the same with any other biologic medication.

She said that she hated to go against my advice (join the club, I thought to myself), and I couldn’t help but smile. "The doctor-patient relationship is like a three-legged race. We have to run in the same direction, or we’ll both fall down!" I told her. She liked that bit of homespun wisdom.

I usually make this folksy comment to invite patients to be active participants in deciding their care, but what was I doing in this situation? Was I sharing decision-making power or was I abdicating responsibility? I reasoned that, since she had already had septic arthritis, she understood the risk she was taking.

I told her that I didn’t agree with all of the assumptions that she had used to make her decision, but by resuming her medication, she spared me an agonizingly tough decision. I don’t think there is any great scientific evidence we can refer to in this situation. This is a gray area that is way off the treatment algorithm, and our only compass is anecdote and clinical judgment. I agreed to refill her medication since she had done well for about 4 months, and she understood the risks. Maybe I should have a special coin to flip for making these tough decisions.

Drug companies regale our patients with remarkable testimonials about the efficacy of their products. These medications work so well that many patients want to resume their medication even after life-threatening infections, but for some reason the ads don’t usually mention that detail. What a marvelous "reality commercial" that might make. "My biologic almost killed me, but I begged the doctor to put me back on it because it worked so well!" If any drug company would like to help me launch a second career in advertising, please drop me a line. It could be the start of a beautiful friendship.

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

Deciding to have patients resume biologic medications after they have had serious infections is one of the toughest decisions I make in practice.

A woman with rheumatoid arthritis developed Escherichia coli septic arthritis of her knee. She survived, but in view of her comorbid conditions, including severe emphysema, I was worried that she might not survive another serious infection and I told her not to go back on etanercept. I tried treating her with various nonbiologic disease modifying drugs that previously had inadequate results: As you might expect, the results were dismal. Her huge swollen joints reminded me of one of my professors with a flair for the dramatic. He would say things in clinic like, "This patient has 2 pounds of synovium in her wrist."

Toward the end, her care was largely palliative and consisted of analgesics and prednisone. Her quality of life was quite diminished because of very severe arthritis. I felt twinges of guilt and helplessness every time I saw her during the last few years of her life.

Another patient on abatacept developed an abscess in his calf. A bit of a curmudgeon, he was quite annoyed that it took the hospital doctors a few days to figure out that he had an abscess after he was originally misdiagnosed with cellulitis. My point of view was exactly the opposite, and I was impressed that the hospital doctors had arrived at the correct diagnosis so quickly.

I tried to explain that cellulitis was a common illness but that calf abscesses were rare. He reluctantly accepted my explanation, or at least he got tired of complaining about it. He is about the same age as the woman I mentioned above, but he is much more robust. Even though he is well into his 70s, he loves to play softball in various senior leagues. He spends his winters in Florida in a kind of perpetual spring training. I was worried about putting him back on his medication, but his overall health was good. If I didn’t put him back on the medication, I knew it would be the end of his softball days, and I’d either lose a patient or, worse yet, have a more-unhappy-than-usual curmudgeon in my office. I have plenty of those already.

A 65-year-old woman with RA in my practice was doing very well on methotrexate and etanercept. She too was hospitalized with septic arthritis of her knee. After she got out of the hospital, she came back to see me. She had already been off etanercept for over a month, her arthritis was getting worse, and she wanted to resume etanercept. I told her not to resume the medication because I thought it was too dangerous. I discussed other options, including adding other nonbiologic medications such as hydroxychloroquine or prednisone, or perhaps a biologic such as rituximab. She didn’t like any of these options and we remained in a standoff, so I asked her to come back in a few months.

She was due back in 2 months but she didn’t come back to the office until 5 months later. When I walked in she told me that she was much better. The nurse had written in the chart, "wants etanercept." I was confused. Why did she want to go back on the medication if her arthritis was doing so well without it? "You’ve been off the etanercept since your septic arthritis, haven’t you? You didn’t resume it, did you?"

She had resumed the medication. My immediate thought was that maybe her family doctor had refilled it for her or, worse yet, I had refilled it inadvertently during a senior moment. Seeing my bewilderment, she reassured me that I wasn’t having a senior moment.

She went on to explain why, for several reasons, she had decided on her own to resume the medication shortly after her previous visit. She had about a 4- month supply of the medication in her refrigerator (probably about $7,000 or $8,000 worth) and she couldn’t bring herself to waste it. Only carefully trained medical professionals can waste money on such a grand scale and not lose any sleep over it. She also assumed that her risk of infection would be the same with any other biologic medication.

She said that she hated to go against my advice (join the club, I thought to myself), and I couldn’t help but smile. "The doctor-patient relationship is like a three-legged race. We have to run in the same direction, or we’ll both fall down!" I told her. She liked that bit of homespun wisdom.

I usually make this folksy comment to invite patients to be active participants in deciding their care, but what was I doing in this situation? Was I sharing decision-making power or was I abdicating responsibility? I reasoned that, since she had already had septic arthritis, she understood the risk she was taking.

I told her that I didn’t agree with all of the assumptions that she had used to make her decision, but by resuming her medication, she spared me an agonizingly tough decision. I don’t think there is any great scientific evidence we can refer to in this situation. This is a gray area that is way off the treatment algorithm, and our only compass is anecdote and clinical judgment. I agreed to refill her medication since she had done well for about 4 months, and she understood the risks. Maybe I should have a special coin to flip for making these tough decisions.

Drug companies regale our patients with remarkable testimonials about the efficacy of their products. These medications work so well that many patients want to resume their medication even after life-threatening infections, but for some reason the ads don’t usually mention that detail. What a marvelous "reality commercial" that might make. "My biologic almost killed me, but I begged the doctor to put me back on it because it worked so well!" If any drug company would like to help me launch a second career in advertising, please drop me a line. It could be the start of a beautiful friendship.

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

Deciding to have patients resume biologic medications after they have had serious infections is one of the toughest decisions I make in practice.

A woman with rheumatoid arthritis developed Escherichia coli septic arthritis of her knee. She survived, but in view of her comorbid conditions, including severe emphysema, I was worried that she might not survive another serious infection and I told her not to go back on etanercept. I tried treating her with various nonbiologic disease modifying drugs that previously had inadequate results: As you might expect, the results were dismal. Her huge swollen joints reminded me of one of my professors with a flair for the dramatic. He would say things in clinic like, "This patient has 2 pounds of synovium in her wrist."

Toward the end, her care was largely palliative and consisted of analgesics and prednisone. Her quality of life was quite diminished because of very severe arthritis. I felt twinges of guilt and helplessness every time I saw her during the last few years of her life.

Another patient on abatacept developed an abscess in his calf. A bit of a curmudgeon, he was quite annoyed that it took the hospital doctors a few days to figure out that he had an abscess after he was originally misdiagnosed with cellulitis. My point of view was exactly the opposite, and I was impressed that the hospital doctors had arrived at the correct diagnosis so quickly.

I tried to explain that cellulitis was a common illness but that calf abscesses were rare. He reluctantly accepted my explanation, or at least he got tired of complaining about it. He is about the same age as the woman I mentioned above, but he is much more robust. Even though he is well into his 70s, he loves to play softball in various senior leagues. He spends his winters in Florida in a kind of perpetual spring training. I was worried about putting him back on his medication, but his overall health was good. If I didn’t put him back on the medication, I knew it would be the end of his softball days, and I’d either lose a patient or, worse yet, have a more-unhappy-than-usual curmudgeon in my office. I have plenty of those already.

A 65-year-old woman with RA in my practice was doing very well on methotrexate and etanercept. She too was hospitalized with septic arthritis of her knee. After she got out of the hospital, she came back to see me. She had already been off etanercept for over a month, her arthritis was getting worse, and she wanted to resume etanercept. I told her not to resume the medication because I thought it was too dangerous. I discussed other options, including adding other nonbiologic medications such as hydroxychloroquine or prednisone, or perhaps a biologic such as rituximab. She didn’t like any of these options and we remained in a standoff, so I asked her to come back in a few months.

She was due back in 2 months but she didn’t come back to the office until 5 months later. When I walked in she told me that she was much better. The nurse had written in the chart, "wants etanercept." I was confused. Why did she want to go back on the medication if her arthritis was doing so well without it? "You’ve been off the etanercept since your septic arthritis, haven’t you? You didn’t resume it, did you?"

She had resumed the medication. My immediate thought was that maybe her family doctor had refilled it for her or, worse yet, I had refilled it inadvertently during a senior moment. Seeing my bewilderment, she reassured me that I wasn’t having a senior moment.

She went on to explain why, for several reasons, she had decided on her own to resume the medication shortly after her previous visit. She had about a 4- month supply of the medication in her refrigerator (probably about $7,000 or $8,000 worth) and she couldn’t bring herself to waste it. Only carefully trained medical professionals can waste money on such a grand scale and not lose any sleep over it. She also assumed that her risk of infection would be the same with any other biologic medication.

She said that she hated to go against my advice (join the club, I thought to myself), and I couldn’t help but smile. "The doctor-patient relationship is like a three-legged race. We have to run in the same direction, or we’ll both fall down!" I told her. She liked that bit of homespun wisdom.

I usually make this folksy comment to invite patients to be active participants in deciding their care, but what was I doing in this situation? Was I sharing decision-making power or was I abdicating responsibility? I reasoned that, since she had already had septic arthritis, she understood the risk she was taking.

I told her that I didn’t agree with all of the assumptions that she had used to make her decision, but by resuming her medication, she spared me an agonizingly tough decision. I don’t think there is any great scientific evidence we can refer to in this situation. This is a gray area that is way off the treatment algorithm, and our only compass is anecdote and clinical judgment. I agreed to refill her medication since she had done well for about 4 months, and she understood the risks. Maybe I should have a special coin to flip for making these tough decisions.

Drug companies regale our patients with remarkable testimonials about the efficacy of their products. These medications work so well that many patients want to resume their medication even after life-threatening infections, but for some reason the ads don’t usually mention that detail. What a marvelous "reality commercial" that might make. "My biologic almost killed me, but I begged the doctor to put me back on it because it worked so well!" If any drug company would like to help me launch a second career in advertising, please drop me a line. It could be the start of a beautiful friendship.

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

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.

When I was a medical student in the early 1980s, I did a rotation in neurology. The neurologist I worked with ordered a head CT on every single patient. When I had the temerity to ask, diplomatically, why he ordered so many scans, the neurologist replied: "You have to stick their heads in the machine."

The neurologist explained that he ordered lots of head scans to make sure he "wasn’t crazy." I understood this reply to mean that he ordered all those scans to make sure that he wasn’t missing some dire diagnosis that only a CT would detect. For him, the CT served as a clinical safety net.

The topic of how many tests to order was a recurrent theme throughout my training. As a resident, I met a hematologist who made fun of other doctors for ordering what he dubbed "the hematology six-pack" for the initial evaluation of an anemic patient. He espoused the quaint point of view that a doctor should personally review the peripheral smear and then order a refined set of tests. He expected us to use a microscope and then to start thinking! How retro is that?

During my fellowship I recall a rheumatologist that ordered an ANA, a rheumatoid factor, an ESR, and a CRP on every patient. I asked politely about his broad "shotgun approach" and he told me bluntly, "If I don’t order these tests, someone else will order them, and if they are abnormal, I’ll look foolish!" According to this line of reasoning, you never look foolish for ordering unnecessary or irrelevant tests. Unfortunately, patients usually don’t know what tests are necessary, and they often feel that a doctor who doesn’t order lots of tests is either incompetent or uncaring.

Another professor remarked, "The lab is your scope." Since rheumatologists don’t usually do a lot of fancy or lucrative procedures, our claim to fame as a specialty is our ability to appropriately order and interpret lab tests for rheumatic diseases.

Lately, I have been ordering a lot of tests for tuberculosis screening. Treatment guidelines for patients on biologic medications recommend annual TB screening. I always screen patients for TB before initiating treatment with biologics, but I resisted implementing annual surveillance screening because I thought it was wasteful. A few years ago, I felt compelled to join the bandwagon, lest I start to look foolish or substandard in my care. So, I too started ordering annual TB tests for my patients on biologic medications.

I was explaining this concept to one of my patients with rheumatoid arthritis and dementia. I spent more time speaking to his family and less time speaking directly to him since his dementia had slowly progressed to the point that he couldn’t participate much in the discussion, but he unexpectedly piped up and told me that TB was an abbreviation for "tired butt." I frequently feel the same way when I leave the office late in the afternoon, but I kept that sentiment to myself.

The main choices for TB screening in my office are a blood test or a PPD skin test. The blood test is more expensive than the PPD, but it offers a big convenience factor. If the patient has a PPD, he/she needs to return to the office in 48-72 hours for the nurse to look at the skin test, but if the patient has the blood test, there is no need to come back to the office.

Sometimes my patients with financial problems ask me not to order unnecessary tests. With expensive health care bills, and a bad economy, every dollar counts. In those circumstances when I feel like my back is to the wall, I dust off that much-ignored clinical skill and take a history: Have you had any unexplained fever or weight loss, cough, or bloody sputum? Have you been exposed to anyone with TB? Have you been in jail or in a homeless shelter? On a few occasions, I used negative answers to those questions in lieu of TB testing for patients who couldn’t afford the blood test or a return visit to the office that a PPD would entail. I wouldn’t recommend doing this all the time, but the few times that I have done this for my financially stressed patients, they really appreciated the courtesy of having one fewer test and a smaller bill.

I can’t help but wonder what useful information our profession might collect if our lab requisitions had check boxes for indications such as "I’m afraid of being embarrassed" or "I’m afraid of being sued," or "The patient made me order this even though I didn’t think it was necessary!" Sometimes in the office, I daydream about creating a set of labs and procedures called the unhappy patient profile.

One of my most unhappy patients is a man that I’ve been seeing for a long time for several chronic painful problems including diffuse peripheral neuropathy, back pain, and osteoarthritis. As you might have guessed, he’s also depressed, and it’s hard work to get a smile out of this guy.

One day he asked me to refer him to a pain specialist regarding his back pain. I had mentioned this option several times at previous visits. This seemed like a great opportunity to send this unhappy camper to someone else\'s office and to give me a breather. If anyone asks me if getting a consultation is a good idea when dealing with a difficult patient, my usual advice is "share the wealth." Sending this patient to see a pain specialist certainly seemed more appealing than having him request more pain medication from me. I would probably even have paid his one-way cab fare to the other doctor’s office.

It turned out that my golden opportunity was short lived. No sooner had I referred Mr. Difficult Pain, than I got a message from the pain doctor’s office. They wouldn’t see my patient before he had an MRI scan. They wanted me to help their office efficiency by ordering the MRI before they even saw him.

I didn’t think this patient needed an MRI. If the specialist had ordered the MRI, it wouldn’t have bothered me as much. But the idea of ordering an MRI scan so the specialist could tell my patient to do back exercises and take ibuprofen bothered me deeply. I gave the patient the option of returning to see me again or seeing a different specialist that was willing to see him first and then decide if he needed an MRI scan. He chose to see another pain specialist, and I was happy to take my own advice and share the wealth.

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

When I was a medical student in the early 1980s, I did a rotation in neurology. The neurologist I worked with ordered a head CT on every single patient. When I had the temerity to ask, diplomatically, why he ordered so many scans, the neurologist replied: "You have to stick their heads in the machine."

The neurologist explained that he ordered lots of head scans to make sure he "wasn’t crazy." I understood this reply to mean that he ordered all those scans to make sure that he wasn’t missing some dire diagnosis that only a CT would detect. For him, the CT served as a clinical safety net.

The topic of how many tests to order was a recurrent theme throughout my training. As a resident, I met a hematologist who made fun of other doctors for ordering what he dubbed "the hematology six-pack" for the initial evaluation of an anemic patient. He espoused the quaint point of view that a doctor should personally review the peripheral smear and then order a refined set of tests. He expected us to use a microscope and then to start thinking! How retro is that?

During my fellowship I recall a rheumatologist that ordered an ANA, a rheumatoid factor, an ESR, and a CRP on every patient. I asked politely about his broad "shotgun approach" and he told me bluntly, "If I don’t order these tests, someone else will order them, and if they are abnormal, I’ll look foolish!" According to this line of reasoning, you never look foolish for ordering unnecessary or irrelevant tests. Unfortunately, patients usually don’t know what tests are necessary, and they often feel that a doctor who doesn’t order lots of tests is either incompetent or uncaring.

Another professor remarked, "The lab is your scope." Since rheumatologists don’t usually do a lot of fancy or lucrative procedures, our claim to fame as a specialty is our ability to appropriately order and interpret lab tests for rheumatic diseases.

Lately, I have been ordering a lot of tests for tuberculosis screening. Treatment guidelines for patients on biologic medications recommend annual TB screening. I always screen patients for TB before initiating treatment with biologics, but I resisted implementing annual surveillance screening because I thought it was wasteful. A few years ago, I felt compelled to join the bandwagon, lest I start to look foolish or substandard in my care. So, I too started ordering annual TB tests for my patients on biologic medications.

I was explaining this concept to one of my patients with rheumatoid arthritis and dementia. I spent more time speaking to his family and less time speaking directly to him since his dementia had slowly progressed to the point that he couldn’t participate much in the discussion, but he unexpectedly piped up and told me that TB was an abbreviation for "tired butt." I frequently feel the same way when I leave the office late in the afternoon, but I kept that sentiment to myself.

The main choices for TB screening in my office are a blood test or a PPD skin test. The blood test is more expensive than the PPD, but it offers a big convenience factor. If the patient has a PPD, he/she needs to return to the office in 48-72 hours for the nurse to look at the skin test, but if the patient has the blood test, there is no need to come back to the office.

Sometimes my patients with financial problems ask me not to order unnecessary tests. With expensive health care bills, and a bad economy, every dollar counts. In those circumstances when I feel like my back is to the wall, I dust off that much-ignored clinical skill and take a history: Have you had any unexplained fever or weight loss, cough, or bloody sputum? Have you been exposed to anyone with TB? Have you been in jail or in a homeless shelter? On a few occasions, I used negative answers to those questions in lieu of TB testing for patients who couldn’t afford the blood test or a return visit to the office that a PPD would entail. I wouldn’t recommend doing this all the time, but the few times that I have done this for my financially stressed patients, they really appreciated the courtesy of having one fewer test and a smaller bill.

I can’t help but wonder what useful information our profession might collect if our lab requisitions had check boxes for indications such as "I’m afraid of being embarrassed" or "I’m afraid of being sued," or "The patient made me order this even though I didn’t think it was necessary!" Sometimes in the office, I daydream about creating a set of labs and procedures called the unhappy patient profile.

One of my most unhappy patients is a man that I’ve been seeing for a long time for several chronic painful problems including diffuse peripheral neuropathy, back pain, and osteoarthritis. As you might have guessed, he’s also depressed, and it’s hard work to get a smile out of this guy.

One day he asked me to refer him to a pain specialist regarding his back pain. I had mentioned this option several times at previous visits. This seemed like a great opportunity to send this unhappy camper to someone else\'s office and to give me a breather. If anyone asks me if getting a consultation is a good idea when dealing with a difficult patient, my usual advice is "share the wealth." Sending this patient to see a pain specialist certainly seemed more appealing than having him request more pain medication from me. I would probably even have paid his one-way cab fare to the other doctor’s office.

It turned out that my golden opportunity was short lived. No sooner had I referred Mr. Difficult Pain, than I got a message from the pain doctor’s office. They wouldn’t see my patient before he had an MRI scan. They wanted me to help their office efficiency by ordering the MRI before they even saw him.

I didn’t think this patient needed an MRI. If the specialist had ordered the MRI, it wouldn’t have bothered me as much. But the idea of ordering an MRI scan so the specialist could tell my patient to do back exercises and take ibuprofen bothered me deeply. I gave the patient the option of returning to see me again or seeing a different specialist that was willing to see him first and then decide if he needed an MRI scan. He chose to see another pain specialist, and I was happy to take my own advice and share the wealth.

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

When I was a medical student in the early 1980s, I did a rotation in neurology. The neurologist I worked with ordered a head CT on every single patient. When I had the temerity to ask, diplomatically, why he ordered so many scans, the neurologist replied: "You have to stick their heads in the machine."

The neurologist explained that he ordered lots of head scans to make sure he "wasn’t crazy." I understood this reply to mean that he ordered all those scans to make sure that he wasn’t missing some dire diagnosis that only a CT would detect. For him, the CT served as a clinical safety net.

The topic of how many tests to order was a recurrent theme throughout my training. As a resident, I met a hematologist who made fun of other doctors for ordering what he dubbed "the hematology six-pack" for the initial evaluation of an anemic patient. He espoused the quaint point of view that a doctor should personally review the peripheral smear and then order a refined set of tests. He expected us to use a microscope and then to start thinking! How retro is that?

During my fellowship I recall a rheumatologist that ordered an ANA, a rheumatoid factor, an ESR, and a CRP on every patient. I asked politely about his broad "shotgun approach" and he told me bluntly, "If I don’t order these tests, someone else will order them, and if they are abnormal, I’ll look foolish!" According to this line of reasoning, you never look foolish for ordering unnecessary or irrelevant tests. Unfortunately, patients usually don’t know what tests are necessary, and they often feel that a doctor who doesn’t order lots of tests is either incompetent or uncaring.

Another professor remarked, "The lab is your scope." Since rheumatologists don’t usually do a lot of fancy or lucrative procedures, our claim to fame as a specialty is our ability to appropriately order and interpret lab tests for rheumatic diseases.

Lately, I have been ordering a lot of tests for tuberculosis screening. Treatment guidelines for patients on biologic medications recommend annual TB screening. I always screen patients for TB before initiating treatment with biologics, but I resisted implementing annual surveillance screening because I thought it was wasteful. A few years ago, I felt compelled to join the bandwagon, lest I start to look foolish or substandard in my care. So, I too started ordering annual TB tests for my patients on biologic medications.

I was explaining this concept to one of my patients with rheumatoid arthritis and dementia. I spent more time speaking to his family and less time speaking directly to him since his dementia had slowly progressed to the point that he couldn’t participate much in the discussion, but he unexpectedly piped up and told me that TB was an abbreviation for "tired butt." I frequently feel the same way when I leave the office late in the afternoon, but I kept that sentiment to myself.

The main choices for TB screening in my office are a blood test or a PPD skin test. The blood test is more expensive than the PPD, but it offers a big convenience factor. If the patient has a PPD, he/she needs to return to the office in 48-72 hours for the nurse to look at the skin test, but if the patient has the blood test, there is no need to come back to the office.

Sometimes my patients with financial problems ask me not to order unnecessary tests. With expensive health care bills, and a bad economy, every dollar counts. In those circumstances when I feel like my back is to the wall, I dust off that much-ignored clinical skill and take a history: Have you had any unexplained fever or weight loss, cough, or bloody sputum? Have you been exposed to anyone with TB? Have you been in jail or in a homeless shelter? On a few occasions, I used negative answers to those questions in lieu of TB testing for patients who couldn’t afford the blood test or a return visit to the office that a PPD would entail. I wouldn’t recommend doing this all the time, but the few times that I have done this for my financially stressed patients, they really appreciated the courtesy of having one fewer test and a smaller bill.

I can’t help but wonder what useful information our profession might collect if our lab requisitions had check boxes for indications such as "I’m afraid of being embarrassed" or "I’m afraid of being sued," or "The patient made me order this even though I didn’t think it was necessary!" Sometimes in the office, I daydream about creating a set of labs and procedures called the unhappy patient profile.

One of my most unhappy patients is a man that I’ve been seeing for a long time for several chronic painful problems including diffuse peripheral neuropathy, back pain, and osteoarthritis. As you might have guessed, he’s also depressed, and it’s hard work to get a smile out of this guy.

One day he asked me to refer him to a pain specialist regarding his back pain. I had mentioned this option several times at previous visits. This seemed like a great opportunity to send this unhappy camper to someone else\'s office and to give me a breather. If anyone asks me if getting a consultation is a good idea when dealing with a difficult patient, my usual advice is "share the wealth." Sending this patient to see a pain specialist certainly seemed more appealing than having him request more pain medication from me. I would probably even have paid his one-way cab fare to the other doctor’s office.

It turned out that my golden opportunity was short lived. No sooner had I referred Mr. Difficult Pain, than I got a message from the pain doctor’s office. They wouldn’t see my patient before he had an MRI scan. They wanted me to help their office efficiency by ordering the MRI before they even saw him.

I didn’t think this patient needed an MRI. If the specialist had ordered the MRI, it wouldn’t have bothered me as much. But the idea of ordering an MRI scan so the specialist could tell my patient to do back exercises and take ibuprofen bothered me deeply. I gave the patient the option of returning to see me again or seeing a different specialist that was willing to see him first and then decide if he needed an MRI scan. He chose to see another pain specialist, and I was happy to take my own advice and share the wealth.

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

One of the mementos I have left over from my training days is a small notebook with a list of the procedures I performed. It reads like an accounting ledger, and gives the impression that procedures are all very calm and matter of fact. Fortunately for my sanity, most procedures are very calm and routine, but there are notable exceptions.

One of my partner’s former patients described the last time he performed an arthrocentesis on her knee. "I don’t know what came over me, Doc. I just sat up all of a sudden and I pushed him away with both hands." Apparently, my partner didn’t care for this deviation from standard procedure, at least to judge from the patient’s recounting of the tale. "He got real red in the face and he walked around and around and he told me to get the hell out."

Now it was my turn to work on her knee.

She was already lying on her back on the exam table and I was prepping her swollen knee with povidone-iodine. At this point, I felt I could no longer politely back out, despite my growing second thoughts about doing the procedure. As I was glumly going through the motions, she sat bolt upright to describe her cherished memory of her assault on my colleague. She might have gone on to demonstrate on me the exact method of shoving that she had visited upon my partner, except that her husband restrained both of her arms and gently settled her back on the table again.

My aplomb was already somewhat shaken, and I think the patient had the same effect on the nurse who was bravely trying to assist me. I resumed my work, but she popped up about five more times – all before I even numbed her skin with xylocaine. With each new pop up, her husband, the pop-up blocker, dutifully popped her back down. He looked as if he was used to this role.

She screamed during the arthrocentesis. It was the sort of primordial scream that gives obstetricians gray hair early in their careers. "This is worse than having a baby," she informed me. I finally convinced her that she had not delivered any progeny, just one or two tubes of synovial fluid.

The screaming caused the waiting room to empty out a bit. Patients with less fortitude fled for their get-away vehicles, so I had a few extra minutes to steady my nerves before I had to see the other patients of the day. I instructed the nurse to put this patient’s name on our "Valium List". If she ever again needs arthrocentesis, she has to have a sedative first. Better yet, maybe I should take the sedative.

The worst arthrocentesis of my career occurred when I was a rheumatology fellow at the Cincinnati VA. I was trying to treat an older man with arthritic knees to whom I’ll refer as ‘the general’. There wasn’t a nurse available to help me, so I was alone with the patient and his wife. I had already finished injecting his creaky old knee without difficulty, when the general told me he felt funny.

"Are you okay?" I asked.

This must have been prescient on my part, since "Are you okay?" is the same question that is always addressed to CPR mannequins or patients just before you start pounding on their chest. My inquiry to the general was more of a beseeching request than a question. "Oh please don’t code, oh please don’t do that!"

He gave me a sort of noncommittal reply but my reassurance was short lived as he proceeded to turn purplish gray, stopped talking, and lost his pulse. The general’s wife didn’t like the looks of the situation. I threw her out of the room as gracefully as possible and called a code.

The house staff came barreling in with the "crash cart," possibly trampling the general’s wife and almost trampling me. Fortunately for everyone involved, the general had already started to moan and groan and show some small signs of life before the house staff began CPR and cracked all his old ribs.

All’s well that ends well. The general got a few days’ stay in the hospital and he forgot all about his arthritis. The general’s wife avoided widowhood, and I avoided the supreme professional embarrassment of having to write ‘arthrocentesis’ as the cause of the general’s death.

I would feel remiss if I didn’t mention the patient who looked like Robert Redford. Actually, he looked chronically ill, but he had this charming delusion that he looked like Robert Redford, and to disabuse him of this notion could only have served to make him feel worse. Despite his arthritis and psychiatric problems, he was quite pleasant. He always assumed that I was a regular at the country club. Although I explained to him that I spent my Sundays at K-Mart rather than the country club, he always asked me about life at "the club."

He was also given to screaming and squirming during arthrocentesis but at least he never pushed me. His arthritic knees frequently needed to be drained, and although the procedure didn’t hurt him physically, (a little local anesthetic works wonders), imagining a needle in his knee caused him intense mental suffering. I usually tried to put visual imagery to work for him by asking him to imagine he was someplace pleasant, but I didn’t have much success.

On one occasion, while drawing multiple vials of synovial fluid from his knee, I stopped working because he was moaning and groaning and squirming. I left the needle in his knee and asked, "Am I hurting you?"

He seemed surprised by the question. "No, Doc, why do you ask?"

"Oh, I don’t know – just curious I guess."

One of my few fond memories of internship was an exhortation from my resident: "No procedure should hurt." I always think of this lofty goal when I glove up for a procedure. Sometimes we fall short of the mark, but our professional pride always leads us to stretch the truth a bit and conclude our procedure note with the standard phrase, "The patient tolerated the procedure well." In some circumstances, the patient tolerated the procedure better than the doctor did.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

One of the mementos I have left over from my training days is a small notebook with a list of the procedures I performed. It reads like an accounting ledger, and gives the impression that procedures are all very calm and matter of fact. Fortunately for my sanity, most procedures are very calm and routine, but there are notable exceptions.

One of my partner’s former patients described the last time he performed an arthrocentesis on her knee. "I don’t know what came over me, Doc. I just sat up all of a sudden and I pushed him away with both hands." Apparently, my partner didn’t care for this deviation from standard procedure, at least to judge from the patient’s recounting of the tale. "He got real red in the face and he walked around and around and he told me to get the hell out."

Now it was my turn to work on her knee.

She was already lying on her back on the exam table and I was prepping her swollen knee with povidone-iodine. At this point, I felt I could no longer politely back out, despite my growing second thoughts about doing the procedure. As I was glumly going through the motions, she sat bolt upright to describe her cherished memory of her assault on my colleague. She might have gone on to demonstrate on me the exact method of shoving that she had visited upon my partner, except that her husband restrained both of her arms and gently settled her back on the table again.

My aplomb was already somewhat shaken, and I think the patient had the same effect on the nurse who was bravely trying to assist me. I resumed my work, but she popped up about five more times – all before I even numbed her skin with xylocaine. With each new pop up, her husband, the pop-up blocker, dutifully popped her back down. He looked as if he was used to this role.

She screamed during the arthrocentesis. It was the sort of primordial scream that gives obstetricians gray hair early in their careers. "This is worse than having a baby," she informed me. I finally convinced her that she had not delivered any progeny, just one or two tubes of synovial fluid.

The screaming caused the waiting room to empty out a bit. Patients with less fortitude fled for their get-away vehicles, so I had a few extra minutes to steady my nerves before I had to see the other patients of the day. I instructed the nurse to put this patient’s name on our "Valium List". If she ever again needs arthrocentesis, she has to have a sedative first. Better yet, maybe I should take the sedative.

The worst arthrocentesis of my career occurred when I was a rheumatology fellow at the Cincinnati VA. I was trying to treat an older man with arthritic knees to whom I’ll refer as ‘the general’. There wasn’t a nurse available to help me, so I was alone with the patient and his wife. I had already finished injecting his creaky old knee without difficulty, when the general told me he felt funny.

"Are you okay?" I asked.

This must have been prescient on my part, since "Are you okay?" is the same question that is always addressed to CPR mannequins or patients just before you start pounding on their chest. My inquiry to the general was more of a beseeching request than a question. "Oh please don’t code, oh please don’t do that!"

He gave me a sort of noncommittal reply but my reassurance was short lived as he proceeded to turn purplish gray, stopped talking, and lost his pulse. The general’s wife didn’t like the looks of the situation. I threw her out of the room as gracefully as possible and called a code.

The house staff came barreling in with the "crash cart," possibly trampling the general’s wife and almost trampling me. Fortunately for everyone involved, the general had already started to moan and groan and show some small signs of life before the house staff began CPR and cracked all his old ribs.

All’s well that ends well. The general got a few days’ stay in the hospital and he forgot all about his arthritis. The general’s wife avoided widowhood, and I avoided the supreme professional embarrassment of having to write ‘arthrocentesis’ as the cause of the general’s death.

I would feel remiss if I didn’t mention the patient who looked like Robert Redford. Actually, he looked chronically ill, but he had this charming delusion that he looked like Robert Redford, and to disabuse him of this notion could only have served to make him feel worse. Despite his arthritis and psychiatric problems, he was quite pleasant. He always assumed that I was a regular at the country club. Although I explained to him that I spent my Sundays at K-Mart rather than the country club, he always asked me about life at "the club."

He was also given to screaming and squirming during arthrocentesis but at least he never pushed me. His arthritic knees frequently needed to be drained, and although the procedure didn’t hurt him physically, (a little local anesthetic works wonders), imagining a needle in his knee caused him intense mental suffering. I usually tried to put visual imagery to work for him by asking him to imagine he was someplace pleasant, but I didn’t have much success.

On one occasion, while drawing multiple vials of synovial fluid from his knee, I stopped working because he was moaning and groaning and squirming. I left the needle in his knee and asked, "Am I hurting you?"

He seemed surprised by the question. "No, Doc, why do you ask?"

"Oh, I don’t know – just curious I guess."

One of my few fond memories of internship was an exhortation from my resident: "No procedure should hurt." I always think of this lofty goal when I glove up for a procedure. Sometimes we fall short of the mark, but our professional pride always leads us to stretch the truth a bit and conclude our procedure note with the standard phrase, "The patient tolerated the procedure well." In some circumstances, the patient tolerated the procedure better than the doctor did.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

One of the mementos I have left over from my training days is a small notebook with a list of the procedures I performed. It reads like an accounting ledger, and gives the impression that procedures are all very calm and matter of fact. Fortunately for my sanity, most procedures are very calm and routine, but there are notable exceptions.

One of my partner’s former patients described the last time he performed an arthrocentesis on her knee. "I don’t know what came over me, Doc. I just sat up all of a sudden and I pushed him away with both hands." Apparently, my partner didn’t care for this deviation from standard procedure, at least to judge from the patient’s recounting of the tale. "He got real red in the face and he walked around and around and he told me to get the hell out."

Now it was my turn to work on her knee.

She was already lying on her back on the exam table and I was prepping her swollen knee with povidone-iodine. At this point, I felt I could no longer politely back out, despite my growing second thoughts about doing the procedure. As I was glumly going through the motions, she sat bolt upright to describe her cherished memory of her assault on my colleague. She might have gone on to demonstrate on me the exact method of shoving that she had visited upon my partner, except that her husband restrained both of her arms and gently settled her back on the table again.

My aplomb was already somewhat shaken, and I think the patient had the same effect on the nurse who was bravely trying to assist me. I resumed my work, but she popped up about five more times – all before I even numbed her skin with xylocaine. With each new pop up, her husband, the pop-up blocker, dutifully popped her back down. He looked as if he was used to this role.

She screamed during the arthrocentesis. It was the sort of primordial scream that gives obstetricians gray hair early in their careers. "This is worse than having a baby," she informed me. I finally convinced her that she had not delivered any progeny, just one or two tubes of synovial fluid.

The screaming caused the waiting room to empty out a bit. Patients with less fortitude fled for their get-away vehicles, so I had a few extra minutes to steady my nerves before I had to see the other patients of the day. I instructed the nurse to put this patient’s name on our "Valium List". If she ever again needs arthrocentesis, she has to have a sedative first. Better yet, maybe I should take the sedative.

The worst arthrocentesis of my career occurred when I was a rheumatology fellow at the Cincinnati VA. I was trying to treat an older man with arthritic knees to whom I’ll refer as ‘the general’. There wasn’t a nurse available to help me, so I was alone with the patient and his wife. I had already finished injecting his creaky old knee without difficulty, when the general told me he felt funny.

"Are you okay?" I asked.

This must have been prescient on my part, since "Are you okay?" is the same question that is always addressed to CPR mannequins or patients just before you start pounding on their chest. My inquiry to the general was more of a beseeching request than a question. "Oh please don’t code, oh please don’t do that!"

He gave me a sort of noncommittal reply but my reassurance was short lived as he proceeded to turn purplish gray, stopped talking, and lost his pulse. The general’s wife didn’t like the looks of the situation. I threw her out of the room as gracefully as possible and called a code.

The house staff came barreling in with the "crash cart," possibly trampling the general’s wife and almost trampling me. Fortunately for everyone involved, the general had already started to moan and groan and show some small signs of life before the house staff began CPR and cracked all his old ribs.

All’s well that ends well. The general got a few days’ stay in the hospital and he forgot all about his arthritis. The general’s wife avoided widowhood, and I avoided the supreme professional embarrassment of having to write ‘arthrocentesis’ as the cause of the general’s death.

I would feel remiss if I didn’t mention the patient who looked like Robert Redford. Actually, he looked chronically ill, but he had this charming delusion that he looked like Robert Redford, and to disabuse him of this notion could only have served to make him feel worse. Despite his arthritis and psychiatric problems, he was quite pleasant. He always assumed that I was a regular at the country club. Although I explained to him that I spent my Sundays at K-Mart rather than the country club, he always asked me about life at "the club."

He was also given to screaming and squirming during arthrocentesis but at least he never pushed me. His arthritic knees frequently needed to be drained, and although the procedure didn’t hurt him physically, (a little local anesthetic works wonders), imagining a needle in his knee caused him intense mental suffering. I usually tried to put visual imagery to work for him by asking him to imagine he was someplace pleasant, but I didn’t have much success.

On one occasion, while drawing multiple vials of synovial fluid from his knee, I stopped working because he was moaning and groaning and squirming. I left the needle in his knee and asked, "Am I hurting you?"

He seemed surprised by the question. "No, Doc, why do you ask?"

"Oh, I don’t know – just curious I guess."

One of my few fond memories of internship was an exhortation from my resident: "No procedure should hurt." I always think of this lofty goal when I glove up for a procedure. Sometimes we fall short of the mark, but our professional pride always leads us to stretch the truth a bit and conclude our procedure note with the standard phrase, "The patient tolerated the procedure well." In some circumstances, the patient tolerated the procedure better than the doctor did.

This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

If the nurse at the hospital was surprised to see me, a senior physician, groveling under a desk outside a patient’s room, she hid her reaction nicely. Maybe she assumed that I had lost a contact lens, pen, stethoscope, pager, or my sanity. Maybe she thought I just wanted to commune with dust bunnies, or perhaps she had grown accustomed to people doing strange things where computers are concerned.

My technological woes at the hospital began a year or two ago when the Information Technology people at the hospital made a great leap of progress and prowess called the "simplified sign in" (SSI). In the dark ages of computing, people needed to have about 101 passwords for everything from the electronic medical records (EMR) system to the water fountain. To maintain proper cyber security, all 101 passwords needed to be changed every month. To simplify this password morass, SSI put a small plastic medallion on the back of my hospital photo ID. To access the EMR I just swipe my ID badge over a small gizmo with a red LED connected to the hospital computers. The gizmo is supposed to give a welcome beep and let me use the EMR without the need for passwords. Or at least I thought that was the goal of the exercise.

Keep in mind that accessing the EMR is a necessity for patient care. In the bygone days of paper medical records, doing a hospital consult involved flipping a lot of pages in a fat chart. Now almost all the information a consultant might need, such as labs results, x-ray reports, findings from history and physical, consult notes, nursing notes, therapy notes, medication lists, and even vital signs are locked up in the EMR. Without access to the EMR, I am unable to offer my learned consultation.

Actually the SSI doesn’t obviate the need for a password, or the endless need for updating passwords. Swiping my ID brings up a sign-in window, and I still have to type in my user name and password. It took me forever to get the little medallion for the back of my ID, because of the erratic hours I keep at the hospital. I avoid the place when possible. When I finally figured out that SSI was just another technological annoyance factor, I felt cheated. The term simplified a euphemism. In reality, SSI made getting into the hospital computer more complicated instead of easier.

On my most recent visit to the hospital, I marched in with grim resolution to face another round of technological humiliation when I remembered that I had my stethoscope, but I didn’t have my hospital ID badge with the plastic medallion. Without the SSI medallion, I would be locked out of the EMR, and doing a consultation would be impossible. So I made myself march out of the hospital and back to the parking lot to get my ID from my briefcase. I consoled myself with the thought that I needed the exercise anyway, even if I didn’t want it.

Trudging back through the hospital tightly clutching my beloved ID, I made my way to the unit of the patient I needed to see. Almost always, the patients I need to see are at the end of a long hall, and tonight wasn’t an exception. I’ve always admired modern units that have a radial design with each patient’s room equidistant from a central nurse’s station. Equidistant seems like such a charming phrase when you are dragging yourself down a long hallway late in the day. Although my hospital is blessed with SSI, the corridors are long serpentine mazes. Maybe the architect was having a bad day when he designed the place.

I finally got to the far end of the hallway and found my patient’s room. Outside each room is a desk attached to the wall, with computers for the doctors and nurses to use. I swiped my ID card, reached the sign-in screen, typed in my user ID and password, and clicked "log-in." After a long pause, one of those angry-looking boxes with a big red X said I "couldn’t be authenticated." Although I felt authentically tired and frustrated, I tried to reason with the stubborn machine. After a few more futile tries I had a sinking feeling that SSI just didn’t like me.

My next step was to call the hospital’s computer help desk. The hospital operator rang the number right away. Surprised that I had reached a human being so quickly (rather than voice mail), I blurted out my problem. Unfortunately, it was the wrong number. The voice on the other end of the line added, "This is Jennifer’s daughter." I had no idea who Jennifer and her daughter were, but I think the operator connected me to a patient’s room, and I can only imagine what this family thought about getting a phone call from a befuddled physician trying to break into the hospital computer system.

I finally reached the computer help person and again explained my digital plight. She reassured me that my 101st password had not expired. All I needed to do was hold down the power button on the PC until it stopped, and then I could reboot the computer, and have another go at SSI. I was not thrilled when I realized that the computer was mounted to the wall under the desk. Still holding the telephone receiver, I got down on my hands and knees and crawled under the desk until I was nose to nose with the power button. I rebooted the computer and swiped my card again, and it still didn’t work.

Luckily for me, the receiver was on a long extension cord and I was able to walk across the hall to another computer. I swiped my card and entered my information, and this time it worked! If I hadn’t mastered SSI, at least I had muddled through this time. Necessity was the mother of invention once more. Eventually I straightened my tie and brushed off the knees of my pants, and I had a few minutes left to go see my patient.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My patient looked a little apprehensive that I might bite her head off and demurely asked, “Doctor, will you fill out my Family Medical Leave Act form?”

No one in their right mind is ever happy about getting extra paperwork from the federal government, but FMLA forms are all pretty much the same, and generally don’t take too long to fill out.

Physical-capacity evaluations are a different situation entirely. These forms are usually sent by the attorneys of patients who seek disability. They take a long time and put a real crimp in my schedule, but I’ll leave that pet peeve for a different column.

“Fine,” I said, with as much fake enthusiasm as I could muster, “it isn’t that big a deal.”

“Oh thank you, doctor!” exclaimed my grateful patient. “I asked my family doctor to fill it out and he said, ‘I don’t want to see another f***ing FMLA form!’?”

I was taken aback. My colleague had, until now, always sported a temperate disposition. What could the government have done to have brought my beloved referring physician to utter an obscenity?

A long time ago, a medical school professor explained that it was the consultant who ended up with the responsibility of doing the patient’s rectal exam. This is the same concept in a new guise: It is the consultant who is stuck with the FMLA form.

In case you think I am exaggerating, I sometimes see new patients and the first thing out of their mouths is how badly they need their FMLA form, but their family doctor refused to fill it out. One family doctor bluntly wrote in the progress notes of a patient with fibromyalgia that he would not fill out an FMLA form, but he would try to get the patient an appointment with a rheumatologist ASAP. Until that moment, I had never realized that filling out FMLA paperwork constituted a medical emergency.

The FMLA is really a simple concept: Patients or caregivers who need time off work for medical issues should be allowed to take unpaid leave without losing their jobs. One patient told me that if he had three absences from work in a year he’d lose his job unless he had documentation that he’d been in the hospital, that he’d been at a funeral (not his own), or that he had an FMLA form. How could such a simple idea become so complicated?

One thing that annoys me is filling out the same form for the same patient with the same diagnosis over and over and over. I often get the idea that somewhere deep in the bowels of corporate management, someone came up with a passive-aggressive policy of repetition and attrition to wear out the wills of patients (and their physicians) who were trying to take off time to which they were legally entitled.

I told one of my stable FMLA patients to schedule a 4-month follow-up appointment. She explained that her work wouldn’t honor her FMLA unless she had a new form filled out every 2 months. I nobly volunteered to fill it out in 2 months’ time and have her return to see me in 4 months. She was apologetic, but said that her job insisted that she had to be reevaluated by the doctor every 2 months. And people wonder why health care is so expensive in the United States! I wonder if patients in other countries are required to have extra visits just to fill out FMLA forms.

I have compensated for this bureaucratic madness to some extent by keeping copies of all FMLA forms in the chart. If a patient has had an FMLA form previously, the nurse fills out the new form exactly like the old form, fills in the correct date, and all I have to do is sign my name. This helps to keep the paperwork at a relatively painless level.

FMLA forms usually ask in what way the applicant qualifies for an FMLA leave. There are usually six categories. Most of my patients are in category 4, which indicates a chronic medical condition requiring follow-up care. Pregnancy is another category, but that is almost never an issue for my rheumatology FMLA patients.

The most difficult question is how much time off work I think the patient will need. In other words, I need to gaze deep into my crystal ball (or my electronic medical records computer screen) and predict how many hours, days, or weeks my patient will be absent because of a flare of their chronic condition. How am I supposed to know? If I could predict the future as well as the federal government thinks I can, I could have become a successful day trader.

In the best-case scenario, my patient reassures me that she rarely misses any time from the office but needs to have the FMLA on file with her human resources office so she isn’t “written up” or penalized if she has to have a medical absence. The much more difficult dilemma is the patient who tells me he needs to allow a few days off per month because of fatigue and difficulty getting out of bed. If I took off 3 days a month because of fatigue, I could lose my practice, or worse yet – gasp – my column!

Most agonizing of all are the FMLA cheats, those patients who game the system. One corporation called me to explain that they allowed for paid FMLA days off. That was an eye opener for me, and we agreed that every time my patient took an FMLA day he’d have to notify me. It’s easy to fill out these forms and lose track of their practical consequences, but once the patient’s FMLA days led to a bunch of annoying phone calls and messages from the company, I got the point. When his FMLA paperwork was up for renewal at his next visit, I bluntly told him that I could not justify the amount of time he was taking off work. Thanks to my splendid care, his arthritis was doing well, so he no longer needed all those paid days off. Although my patient couldn’t argue the point, he didn’t look very happy. Whatever expletive he was thinking, though, he kept to himself.

This column, “Inside Rheum,” regularly appears in Rheumatology News. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

I do not know how well you keep up with your professional reading, but if truth be told, I gave up years ago.

Every day, my small desk is washed by tidal waves of paper and journals that even the speediest reader could never hope to wade through, especially after a long day with patients.

In my training days, I used to blithely toss old journals into the wastebasket across the house-staff lounge when my locker got too full. I used to call this “the 20-foot journal toss,” giving the menial chore a jaunty Olympian sound. Back in those dark ages, recycling bins were not nearly as ubiquitous as they are now and throwing out unwanted paper was the norm. But the practice of tossing expensive, landfill-glutting journals into the garbage has become untenable. I now have a green recycling bag strategically located in the small gap between my desk and the bookcase, and when the piles become high enough to teeter, I quietly transfer the almost-pristine journals into the bag.

I know what you’re thinking: There are doctors in Third World countries who would love to have my discarded journals. I’ve checked this out. Numerous organizations help provide such resources to developing countries, but what they really want is a donation of money, not the journals themselves. And no one in my state seems to be interested in hauling away my piles of journals, even if they’re free for the taking.

Recycling presents another, more subtle issue. Perhaps bystanders would stop off at the local dumpster with their piles of newspapers, see my glossy journals in there, and think, “Gee, what kind of doctor throws away journals? They look as if they haven’t even been read.” Even if I had been careful to remove my name, I fretted that some local sleuth would track me down and publicly shame me.

For a long while, I was stuck. I could no longer bring myself to jam the journals into the wastebasket, I couldn’t give them away, and even recycling wasn’t completely free of risk. I looked in the local recycling dumpster this morning and saw a pediatric journal that some other doc must have thrown out. It was heartening to know that someone else had gotten over the journal-recycling inhibition – or perhaps never had it in the first place.

My current solution is less bold and a bit sneakier: I transport the journals and the household recycling up to the dumpster at the same time, putting the journals in first and then throwing all the bags of newspapers on top of them. You would actually have to climb into the dumpster and root around to discover my discarded journals. That’s not commonly done in my neighborhood.

I’m not suggesting that you crawl around in the dumpster, although I did have that experience once. My wife likes to store supplies in paper sacks in our garage. The problem is that our garage is full of bags that all look more or less the same. One morning, I was gleefully hauling the last sack over from the car when a new box of tissues on top of the dumpster debris caught my attention. “Who recycled that? How careless and dumb,” I thought to myself. As my eyes scanned the dumpster’s contents, I saw more boxes of tissues, a new package of computer CD-ROMs, a new calculator, a package of pens, and a fresh set of glue sticks. It dawned on me that in my zeal, I had grabbed a bag of new school supplies that my wife had stored in the garage. No matter how much I jumped up and down in protest of my own stupidity, I’d need 10-foot arms to reach all the supplies that were now in the far recesses of the bin. I had to drive home and fetch a stepladder. As I perched on the dumpster’s rim, I prayed that none of my neighbors would take my photo or steal the ladder. Now I’m more circumspect when I load the recycling bags into the back seat of the car.

Most medical journals are available online. Having a pile of journals sitting on my desk is messy, but at least the pile goads me into a little bit of reading. A virtual journal sitting in my e-mail inbox is not going to have that beneficial effect.

Furthermore, I can’t imagine that anyone would subscribe to the notion that the virtual journal and the hard copy should have the same price tag. Let’s save trees and the environment too, but at least give me a discount to encourage the nobler choice. Until that great day arrives, however, I doubt you will be able to see the pretend-wood veneer of my beleaguered desk.

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

I do not know how well you keep up with your professional reading, but if truth be told, I gave up years ago.

Every day, my small desk is washed by tidal waves of paper and journals that even the speediest reader could never hope to wade through, especially after a long day with patients.

In my training days, I used to blithely toss old journals into the wastebasket across the house-staff lounge when my locker got too full. I used to call this “the 20-foot journal toss,” giving the menial chore a jaunty Olympian sound. Back in those dark ages, recycling bins were not nearly as ubiquitous as they are now and throwing out unwanted paper was the norm. But the practice of tossing expensive, landfill-glutting journals into the garbage has become untenable. I now have a green recycling bag strategically located in the small gap between my desk and the bookcase, and when the piles become high enough to teeter, I quietly transfer the almost-pristine journals into the bag.

I know what you’re thinking: There are doctors in Third World countries who would love to have my discarded journals. I’ve checked this out. Numerous organizations help provide such resources to developing countries, but what they really want is a donation of money, not the journals themselves. And no one in my state seems to be interested in hauling away my piles of journals, even if they’re free for the taking.

Recycling presents another, more subtle issue. Perhaps bystanders would stop off at the local dumpster with their piles of newspapers, see my glossy journals in there, and think, “Gee, what kind of doctor throws away journals? They look as if they haven’t even been read.” Even if I had been careful to remove my name, I fretted that some local sleuth would track me down and publicly shame me.

For a long while, I was stuck. I could no longer bring myself to jam the journals into the wastebasket, I couldn’t give them away, and even recycling wasn’t completely free of risk. I looked in the local recycling dumpster this morning and saw a pediatric journal that some other doc must have thrown out. It was heartening to know that someone else had gotten over the journal-recycling inhibition – or perhaps never had it in the first place.

My current solution is less bold and a bit sneakier: I transport the journals and the household recycling up to the dumpster at the same time, putting the journals in first and then throwing all the bags of newspapers on top of them. You would actually have to climb into the dumpster and root around to discover my discarded journals. That’s not commonly done in my neighborhood.

I’m not suggesting that you crawl around in the dumpster, although I did have that experience once. My wife likes to store supplies in paper sacks in our garage. The problem is that our garage is full of bags that all look more or less the same. One morning, I was gleefully hauling the last sack over from the car when a new box of tissues on top of the dumpster debris caught my attention. “Who recycled that? How careless and dumb,” I thought to myself. As my eyes scanned the dumpster’s contents, I saw more boxes of tissues, a new package of computer CD-ROMs, a new calculator, a package of pens, and a fresh set of glue sticks. It dawned on me that in my zeal, I had grabbed a bag of new school supplies that my wife had stored in the garage. No matter how much I jumped up and down in protest of my own stupidity, I’d need 10-foot arms to reach all the supplies that were now in the far recesses of the bin. I had to drive home and fetch a stepladder. As I perched on the dumpster’s rim, I prayed that none of my neighbors would take my photo or steal the ladder. Now I’m more circumspect when I load the recycling bags into the back seat of the car.

Most medical journals are available online. Having a pile of journals sitting on my desk is messy, but at least the pile goads me into a little bit of reading. A virtual journal sitting in my e-mail inbox is not going to have that beneficial effect.

Furthermore, I can’t imagine that anyone would subscribe to the notion that the virtual journal and the hard copy should have the same price tag. Let’s save trees and the environment too, but at least give me a discount to encourage the nobler choice. Until that great day arrives, however, I doubt you will be able to see the pretend-wood veneer of my beleaguered desk.

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

I do not know how well you keep up with your professional reading, but if truth be told, I gave up years ago.

Every day, my small desk is washed by tidal waves of paper and journals that even the speediest reader could never hope to wade through, especially after a long day with patients.

In my training days, I used to blithely toss old journals into the wastebasket across the house-staff lounge when my locker got too full. I used to call this “the 20-foot journal toss,” giving the menial chore a jaunty Olympian sound. Back in those dark ages, recycling bins were not nearly as ubiquitous as they are now and throwing out unwanted paper was the norm. But the practice of tossing expensive, landfill-glutting journals into the garbage has become untenable. I now have a green recycling bag strategically located in the small gap between my desk and the bookcase, and when the piles become high enough to teeter, I quietly transfer the almost-pristine journals into the bag.

I know what you’re thinking: There are doctors in Third World countries who would love to have my discarded journals. I’ve checked this out. Numerous organizations help provide such resources to developing countries, but what they really want is a donation of money, not the journals themselves. And no one in my state seems to be interested in hauling away my piles of journals, even if they’re free for the taking.

Recycling presents another, more subtle issue. Perhaps bystanders would stop off at the local dumpster with their piles of newspapers, see my glossy journals in there, and think, “Gee, what kind of doctor throws away journals? They look as if they haven’t even been read.” Even if I had been careful to remove my name, I fretted that some local sleuth would track me down and publicly shame me.

For a long while, I was stuck. I could no longer bring myself to jam the journals into the wastebasket, I couldn’t give them away, and even recycling wasn’t completely free of risk. I looked in the local recycling dumpster this morning and saw a pediatric journal that some other doc must have thrown out. It was heartening to know that someone else had gotten over the journal-recycling inhibition – or perhaps never had it in the first place.

My current solution is less bold and a bit sneakier: I transport the journals and the household recycling up to the dumpster at the same time, putting the journals in first and then throwing all the bags of newspapers on top of them. You would actually have to climb into the dumpster and root around to discover my discarded journals. That’s not commonly done in my neighborhood.

I’m not suggesting that you crawl around in the dumpster, although I did have that experience once. My wife likes to store supplies in paper sacks in our garage. The problem is that our garage is full of bags that all look more or less the same. One morning, I was gleefully hauling the last sack over from the car when a new box of tissues on top of the dumpster debris caught my attention. “Who recycled that? How careless and dumb,” I thought to myself. As my eyes scanned the dumpster’s contents, I saw more boxes of tissues, a new package of computer CD-ROMs, a new calculator, a package of pens, and a fresh set of glue sticks. It dawned on me that in my zeal, I had grabbed a bag of new school supplies that my wife had stored in the garage. No matter how much I jumped up and down in protest of my own stupidity, I’d need 10-foot arms to reach all the supplies that were now in the far recesses of the bin. I had to drive home and fetch a stepladder. As I perched on the dumpster’s rim, I prayed that none of my neighbors would take my photo or steal the ladder. Now I’m more circumspect when I load the recycling bags into the back seat of the car.

Most medical journals are available online. Having a pile of journals sitting on my desk is messy, but at least the pile goads me into a little bit of reading. A virtual journal sitting in my e-mail inbox is not going to have that beneficial effect.

Furthermore, I can’t imagine that anyone would subscribe to the notion that the virtual journal and the hard copy should have the same price tag. Let’s save trees and the environment too, but at least give me a discount to encourage the nobler choice. Until that great day arrives, however, I doubt you will be able to see the pretend-wood veneer of my beleaguered desk.

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