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Friday, January 4, 2013

Applying the Pareto Principle (80/20 rule) to rheumatology

"If you can't explain it to a six year old, you don't understand it yourself."
--Albert Einstein


Since entering the field of rheumatology, I have too frequently heard comments from clinicians admitting their lack of knowledge and understanding in the field of rheumatology.

I understand why rheumatology has gotten a reputation as being difficult. The basis for the understanding of rheumatic conditions is the immune system, where our knowledge is becoming ever complex. Many of the rheumatic conditions are uncommon, so clinicians are less comfortable recognizing and treating them. To make things worse, we order a number of oddly named antibodies and use medications that affect the immune system in strange ways.

Fortunately, the basics of rheumatology are not extremely difficult to understand.

The Pareto Principle (80/20 rule)
The Pareto Principle says that 80% of the results come from 20% of the effort, knowledge, or resources. This rule has been shown effective in numerous fields outside of medicine, especially business and finance, and can be used as an effective technique to approach any difficult topic.

With this in mind, I'll try to focus on the 20% of rheumatology that I think is the most high-yield for those outside of rheumatology to understand.

(Sorry, fellow rheumatologists, this post isn't intended to teach you much of anything, but might be helpful when you give guidance or mentor others. I would greatly appreciate any additions or corrections in the comments section below).

The unifying mechanism in the rheumatologic diseases is inflammation
Recognition of inflammation is really the first step in thinking about the rheumatologic diseases. With few exceptions, the first thing I'm trying to decide with every new patient I see in the office is whether an inflammatory condition is present, or not.

Recognition of inflammation goes back to the very basics of what we are taught in medicine: the history and physical exam
Joint pain is an extremely common complaint. Being able to differentiate inflammatory from non-inflammatory joint pain is likely the most high yield knowledge in rheumatology. Differentiating these two processes is important because the treatment strategy will vary greatly between the two types.

Taking a pain history: OPQRST
Many of us are taught early in our training the mnemonic "OPQRST" to remember the components of a taking a history. While likely very basic, this is worth reviewing, as details discovered here can greatly change suspicion for inflammation later on.

--Onset. When did the symptoms start? Rapid or slow onset?
--Provoking/palliating factors. How are the symptoms affected by use? What about rest? Do anti-inflammatories or other medications help? What else have they tried?
--Quality (description) of the pain. – Dull, aching, stiffness, burning, etc?
--Regions/radiation. What joints or other areas are involved? (Remember to ask about the neck and back) Does the pain radiate from one area to another?
--Severity. Generally rated on a scale of 0-10
--Timing. Constant or intermittent symptoms? Does it change throughout the day (morning stiffness)?

In terms of differentiating inflammatory from non-inflammatory causes, the most helpful are the provoking/palliating factors, and the timing of the symptoms. Inflammatory arthritis is typically associated with pain that is worst in the morning or after resting, with stiffness typically lasting 30-60 minutes or more, and improves with activity.

The complete review of systems: finding the puzzle pieces
The next most powerful tool that rheumatologists use is the complete review of systems. Lack of comfort with what questions to ask, or the feeling that this takes too much time, is likely another reason that many clinicians are uncomfortable with rheumatology.

In reality, the puzzle pieces found in the complete review of systems is often where the bigger picture starts to come into place. Feeling overwhelmed? Use the patient as a guide, starting head to toe, to help remember features to ask. Use a checklist if needed at first, or consider using this rheumatologic patient history form from the ACR.

The cardinal signs of inflammation on exam: if you don't know what to look for, you won't find it
Most of us are aware of the five cardinal signs of inflammation, but might not have been taught some of the details to look for:
--Dolor (tenderness on palpation)
--Calor (heat): The joint is typically cooler than the surrounding tissues.
--Rubor (redness/erythema)
--Functio laesa (loss of function): Typically decreased ROM due to tenderness. If joint function is normal, consider surrounding tissues as the cause of pain. This can be particularly helpful in differentiating cellulitis and/or bursitis from joint inflammation and septic joints.
--Tumor (swelling): Look for loss of "dimples" around the joint & decreased skin lines over the joint. Feel for the edges of the joint to feel "boggy/squishy" or less distinct. Feel small joint swelling/effusions by pushing with one finger and sensing with the other.

The Rheumatology Image Bank, especially comparing images of rheumatoid arthritis and osteoarthritis is great resource to look further at these details.

A more detailed resource for rheumatologic exam tips can be found here.

Palpating joint inflammation: practice, practice, practice!
With enough practice, you can learn to palpate synovitis (I have taught medical residents to do this in clinic over the course of a morning). Practice palpating your own joints (assuming they are normal), especially the hands. You typically should easily be able to feel the edges of the joint lines, with only the sense of a normal, thin layer of skin separating the joints from your fingers. If you feel boggy/squishy or less distinct joint lines, along with other features from above, inflammation is more likely.

When to order an ANA
This article is a great review of when to order an ANA for our patients. In summary an ANA should be ordered when the pretest odds of autoimmune disease are high, which is based on findings from our history and physical, summarized in Table 1.

Rheumatoid factor (RF): consider causes other than rheumatoid arthritis
Similar to the ANA, the RF should be ordered when the pretest odds of rheumatoid arthritis are high, which requires joint inflammation/synovitis to be present, and increases with the number of affected joints (refer to this excerpt from the 2010 ACR/EULAR RA Classification Criteria for Rheumatoid Arthritis or here for the full article. When suspicion of rheumatoid arthritis is high, typically an anti-CCP is also ordered.

Keep in mind that a positive RF is common in a number of other rheumatic disorders (Sjogren's syndrome and cryoglobulinemia being most common, but the other connective tissue diseases such as lupus to lesser degrees).

The most common other condition that causes a positive RF is hepatitis C infection, which must be ruled out when a positive RF is detected (additionally, hepatitis C infection is associated with an inflammatory arthritis).

Other conditions associated with positive RF include hepatitis B, lymphoproliferative disorders, malignancy, chronic infections, inflammatory lung conditions.

Common mistakes in gout management
When I asked for suggestions for high yield rheumatology topics on Twitter, gout quickly came up multiple times. Since the incidence of gout is on the rise, likely related to increased risk factors (obesity, diabetes, chronic kidney disease, cardiovascular disease, and hypertension), knowledge of appropriate management will only become more important.

Gout management is divided into acute management (typically treated with prednisone; colchicine, or NSAIDs) and management of hyperuricemia.

The management of hyperuricemia is where most errors in management occur, especially failure to lower the uric acid to 6.0 or less. In most patients, this is accomplished by titrating the allopurinol dose every few weeks until this is achieved, and many clinicians fail by never titrating to a high enough dose to reach this goal. Additionally, most patients are placed on prophylaxis against attacks when first initiating medications to lower uric acid, since risk of flare is highest during this time. These topics are covered nicely in a two-part update, published in October 2012.

In closing, I hope this serves as a good starting point for clinicians to become more comfortable in the field of rheumatology. I invite my rheumatology colleagues to post additions, corrections, and any comments below.

Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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