Blood Tests for Rheumatoid Arthritis, part 2

Substantial numbers of RA’ers have “normal” test results

In my last post, I posed the question: Is There a Blood Test for Rheumatoid Arthritis? I told you that the answer is yes – and no. I went on to describe the “yes” by summarizing four principal blood tests used in diagnosing Rheumatoid Arthritis. Now it is time to elaborate upon the “no.”

I found this startling:

You may already know that there is not a blood test to definitively measure Rheumatoid Arthritis. No blood test can be used to precisely diagnose RA in all patients. But just as importantly, there is not a test which can reliably gauge the degree of RA within a patient.

But, wait, it gets more interesting:

The most thorough study of the usefulness of these tests was a large study conducted in both Finland and Tennessee. Almost 2,500 patients were studied over a period of 25 years. The CRP, sed rate (ESR), and Rheumatoid factor (Rf) were all monitored.

Look at some of the results. ESR was normal in 45% (Finland) and 47% (Tennessee) of patients. CRP was normal in 44% and 58%. And all Rheumatoid factor (Rf) tests were negative in 38% and 37% of patients.

Why does this matter?

Doctors commonly use these three tests to “monitor disease activity.” That means they are looking to these numbers to show whether the disease is active and whether a patient’s current treatment plan is adequate. Some doctors are more reliant upon them than others. I have met one rheumatologist who says that he relies upon them completely.

So read this carefully:

Many RA’ers experience plenty of active and damaging Rheumatoid Arthritis while one or all of these indicators are “normal.”

Here are a few cases in point:

~ “Sometimes also patients with rheumatoid arthritis have low CRP response in relation to the severity of the disease.” Axis-shield

~ “By the same token a normal sed rate is meaningless in a patient with known SLE if they are having symptoms of a flare." (Sounds like this rheumatologist considers the lab test pretty useless to measure flares in Lupus.) Nathan Wei, MD, FACP, FACR

~ “However, a low CRP level does not always mean that there is no inflammation present. Levels of CRP may not be increased in persons with rheumatoid arthritis and lupus. The reason for this is not known.” University of Southern California

~ “Many people with active RA have inactive values of ESR/CRP and many with inactive RA have active values.” Journal of Rheum.

~ “Both ESR and CRP were normal in 33% and 42% of patients” in the large study mentioned earlier. Journal of Rheum. abstract

What is the bottom line?

Only a small percentage of RA’ers actually had abnormal results to all three blood tests (ESR, CRP, and Rf) in the huge Finland / Tennessee study. “All 3 tests were abnormal in only 28% in Jyväskylä (Finland) and 23% in Nashville (Tennessee).” The authors of the study concluded: “Normal ESR, CRP, and RF are seen in a substantial proportion of patients with RA at this time.” Journal of Rheum. abstract

There is hope.

I had already spent many grueling hours researching for this series when I happened upon an article entitled The Many Myths of Erythrocyte Sedimentation Rate and C-Reactive Protein. I was thrilled to find a rheumatologist who holds the following viewpoint. “Learning when to ignore a test and when to rely on it lies at the heart of good medical care… It is, perhaps, time for more research about testing and measurement in clinical practice.” I recommend the article in the Journal of Rheumatology by Frederick Wolfe, M.D.

Is There a Typical Rheumatoid Arthritis

Complications to understanding Rheumatoid Arthritis

Rheumatoid Arthritis is a complicated disease. I am not speaking of symptoms, medications, and lifestyle changes. I mean mechanically speaking – on a molecular level. It is complex and multi-level in its schemes.

That is one reason that experiences vary so greatly between RA patients: Which joints are affected? How many joints? How quickly does it spread through the body? Which other body systems are affected? How much destruction is there in the joints? Are additional autoimmune diseases involved? How does the Rheumatoid Arthritis initially present (what I call the “onset story”)?

What is typical Rheumatoid Arthritis?

Last year, my rheumatologist began to say that my Rheumatoid Arthritis was beginning to look atypical. I did not understand that since the only RA that I knew was my own. Around that time, I began to dig in to investigate what is the typical Rheumatoid Arthritis experience.

I wanted to do the research for myself. WHAT is typical? I read everything I could find.

I have read several books and what is called “typical” differs from author to author. But, I also began to scrutinize narratives of RA’ers all over the internet. And I also have connected with many one on one. What I have seen and heard from hundreds of RA’ers has not fit nicely into the neat categories or descriptions of any author.

Questions need answers

Every little thing that I learn raises more questions. If you have been reading this blog, you have heard me raise some of them. Can Rheumatoid Arthritis be understood or cured without answering any of them? I do not believe so.

To read a few of the questions that I have already raised, see The Four Courses of Rheumatoid Arthritis, part 1 , Is This the Best Time to Have Rheumatoid Arthritis, part 3 , and What Makes Diagnosing Rheumatoid Arthritis So Difficult?

The only thing that I am certain of is this:

If there is any discrepancy between the experiences of people with Rheumatoid Arthritis and those who academically describe and define this disease, it is the descriptions that are wrong – not the RA’ers.

It is not that they got their symptoms in the wrong order. Shame on them for not doing their RA right.

It is not that they have fallen short by missing a symptom on the list. How could they be so negligent?

It is NOT that the patients have failed the blood tests. The blood tests have failed the patients. The tests have failed to sufficiently demonstrate the presence of the disease. That is not the patients’ fault.

Why is it so typical to have atypical Rheumatoid Arthritis?

This week, I have driven across three states hoping to find one small part of the answer.

Is This the Best Time to Have Rheumatoid Arthritis? Part 3: Response to RA Mortality Gap

How should we respond to the mortality gap?

Responding seriously

Rheumatoid Arthritis is an inflammatory disease. The progressive toll it takes upon vital organs is well documented. Science Daily: “Rheumatoid arthritis (RA) is associated with a high risk of early death.” Rheumatoid Arthritis requires the same serious response as breast cancer, diabetes, and heart disease.

Response by physicians

Physicians should not neglect to follow up symptoms in Rheumatoid Arthritis patients because they are “chronically” ill and have many ailments. RA-ers may be viewed as having recurrent and persistent complaints. Health care providers can begin to view them as whiners and neglect to investigate every complaint. However, high blood pressure, anemia, osteoporosis, and pneumonia are just as critical in patients who already plagued with Rheumatoid Arthritis.

Response by everyone

At this point, there is so little general knowledge about Rheumatoid Arthritis that RA-ers themselves must go through a period of learning about RA after diagnosis so that they can pursue proper treatment. Family members and society in general must also be educated about RA and the needs of those who have it. Too often, there are no modifications of expectations for those who are suddenly disabled by Rheumatoid Arthritis. That can make it difficult for RA-ers to obtain the assistance that they need.


Responding with research

Rheumatoid Arthritis also requires the same serious research attention as breast cancer, diabetes, and heart disease. Here are a few suggestions to use research to fight the Mortality Gap and make this a truly better time to live if you have Rheumatoid Arthritis:

• Research ought to begin with a focus upon actual patients.
  


• The target of most research ought to be a cure instead of symptom improvement.
  


• The other goal of research should be learning to recognize early Rheumatoid Arthritis so that it can be diagnosed at an earlier stage.

Post blog personal note: I was thinking, it’s not like we hold anyone hostage and make these ransom demands. In fact, we are the ones who are held hostage – by RA! We feel pretty helpless. I also remember that Jesus said our response to the least in our world represents of our response to him.

Parvovirus B19 and Rheumatoid Arthritis: Who is the real fraud?

Does human parvovirus B19 Cause Rheumatoid Arthritis?

There is a counterfeit Rheumatoid Arthritis. But it is only a pretender, so it doesn’t inflict the harm that RA does. It is like a shadow boxer. However, the pain is real – for as long as it lasts.

Human parvovirus B19 is a common childhood virus. It causes Fifth disease, a minor childhood disease which is similar to the measles. There are usually cold symptoms and a low grade fever. There is often a rash on the face which is bright red. It is called “slapped cheek.” But, it’s often so not simple in adult women.

Parvovirus often mimics Rheumatoid Arthritis, causing pain, stiffness, swelling, and disability. Approximately 60% of women who get B19 contract the sudden arthritis in multiple joints. However, children and men who are infected with parvovirus do not usually suffer from such arthralgia.

Normally, joint symptoms last only a couple of weeks. However, in a small percentage of patients, they may last for several weeks to several months. There is also initially a distinctive rash on the trunk and limbs which looks a lot like lace.

Several studies have been done to investigate whether parvovirus B19 is in any way connected with actual Rheumatoid Arthritis. However, they have concluded that it probably is not.

Consider this: the percentage of people who have the B19 antibody (showing they have had the virus) is about 50%. Similar numbers have been shown for Rheumatoid Arthritis patients. If B19 were the cause of Rheumatoid Arthritis, 100% of RA patients would have had the virus.

Studies continue to examine whether parvovirus B19 could be one trigger for Rheumatoid Arthritis. Also, B19 may behave differently in people who have RA. It could be one of those “chicken and egg” questions.

Double Déjà Vu

Researchers say they don’t know what causes human parvovirus, but I met a doctor once who says he does know. In 1998, when my family contracted the disease, I went to an urgent care center on a Sunday. Every joint, especially my cervical spine, was inflamed. I could barely move. I had no idea what was wrong with me. I was terrified. The lacey red rash covered my legs.

The doctor took one look at me and he knew what was wrong. I guess it was too traumatic to tell me to my face since he decided to tell my husband first. He said he was sure he was right.

He told my husband that my joint pain was nothing to worry about. It was caused by my imagination. Yep. Simple as that. And the rash? He looked right at it and said that it did not exist. Whew! According to him, I was not sick; I was a fraud.

Double déjà vu: I wish I could report that he was the worst doctor I have ever met. Unfortunately, though, I have been through the exact same process a few times with regard to Rheumatoid Arthritis. It has been a double déjà vu. First, with the arthritis symptoms; and then, with the “hysterical woman” diagnosis.

Postscript: It was a classic case of parvovirus.

I did take my kids to the pediatrician the following week when they developed the classic B19 symptom of “slapped cheek” rash. My kids were easily diagnosed with the highly contagious “fifth disease” which is caused by human parvovirus. The docs got all excited about how closely our case replicated the photographs in their books.

More information on human parvovirus B19:

Center for Disease Control factpage

Images of fifth disease in a French gynecological journal

A children’s health blog on fifth disease in kids

One study which examines whether parvovirus B19 causes Rheumatoid Arthritis from Annals of Rheumatic Diseases

More Rheumatoid Arthritis Warrior:

What Causes the Fatigue of Rheumatoid Arthritis?

Rheumatoid Arhtritis and Depression

A Memo to Non RA-ers / If you do NOT have RA, please read this

What Makes Diagnosing Rheumatoid Arthritis So Difficult?

Why is it so hard to get a Rheumatoid Arthritis diagnosis? RA-ers ask me that all the time. Why don’t we watch the mini-movie and then we’ll talk?

Video on referrals for Rheumatoid Arthritis:




There are some familiar themes there:

Minimizing:

Rheumatoid Arthritis patients report that healthcare professionals often underrate their symptoms. Sometimes, it is as if doctors are hard of hearing. But, other times it can be worse: they can intentionally discount the patient’s descriptions of the disease. Did you hear the lady say that her doc thought her just a “neurotic teenager”? I know one RA-er who was sent to a psychiatrist instead of a rheumatologist. I have actually seen doctors scoff about RA.

Ignorance:

Astonishing as it is, even many physicians are unable to recognize Rheumatoid Arthritis when confronted with the symptoms. They may not know that many RA-ers are seronegative, like another woman in the video. They frequently have misconceptions of Rheumatoid Arthritis. Otherwise, they may rely too heavily upon the ACR’s 7 guidelines.

Under-diagnosis:

Concerning Rheumatoid Arthritis, misdiagnosis is consistently “under-diagnosis.” Doctors tend to look with skepticism upon portrayals of RA which sound dramatic or extreme. (Who could believe someone could live with this much RA?) This tendency can cause doctors to “miss” Rheumatoid Arthritis entirely, seeing instead less serious conditions.

Consequences:

Some patients in the video stated that they were made to feel that they or their illness was unimportant. While that infuriates me, I actually have more grave reasons to protest. This is about more than hurt feelings. Here are some other consequences:

1) When doctors do not accurately hear what Rheumatoid Arthritis patients recount, it results in delay of an accurate diagnosis of RA. Of course this means either lack of treatment or an inappropriate treatment. Remember the dear mum in the video who was forced into an exercise program to treat her RA? If she had had another condition, instead of RA, she might have improved. However, it made her worse BECAUSE SHE HAD FULL-BLOWN RHEUMATOID ARTHRITIS.

2) If symptoms are not accurately heard, they cannot be accurately recorded. This may hurt the patient’s position with future providers, with long term disease management, and with insurance issues regarding treatment options.

3) Rheumatoid Arthritis is believed to cause permanent damage even during the first months of being symptomatic. Patients are permanently harmed when doctors refuse to hear them and do not refer to specialists or begin treatment.

4) Finally, I believe that one reason scientists can’t find a cure to Rheumatoid Arthritis is that the disease process is not entirely understood. It is impossible to cure what we do not understand. Failing to listen only exacerbates this problem.

Bewildering, huh?

Dangerous thought: what if doctors were hired based on whether they could find the right diagnosis… like plumbers and electricians? Would that help?

Recommended reading: Diagnosing Rheumatoid Arthritis
RA Warrior’s RA
It’s Okay to Laugh if You Have Rheumatoid Arthritis

Functional Measurement of Rheumatoid Arthritis

It’s not only “Where does it hurt,” but also “What are you able to do!"

There are many ways to measure RA. Of course you’ve heard the pincushion jokes. But, blood work is the simplest way to get a picture of what Rheumatoid Arthritis is doing in a body. Sometimes x-rays or other scanning devices can detect damage.

Actual disability is more difficult to appraise, though. Certain symptoms such as pain, stiffness, and weakness are tough to measure. However, they are important indicators of disease severity and progression.

Some doctors might ask patients, “Were does it hurt?” or “How bad does the pain on a 1 to 10 scale?” But, there is another question which is just as important. It is, “What can you do?”

Over the years, doctors have developed several instruments to gauge the disability that Rheumatoid Arthritis causes. They include the Health Assessment Questionnaire (HAQ), the Keitel function test (KFT), and the Arthritis Impact Measurement Scale (AIMS). They attempt to record limitations in joint motion and difficulty performing certain tasks.

The goal is to have a more objective way to measure, record, and predict ability to perform the daily tasks of life. That is sometimes referred to as “Global functional status.” See image; click on it to enlarge it.

Patients are classified according to their ability to perform activities related to these categories: self-care (bathing, dressing, grooming); vocational (job-related tasks); avocational (pleasure or hobby- related tasks). There are four labels based upon which types of tasks a patient can perform.

Measuring functional capacity at the time of diagnosis of Rheumatoid Arthritis is important. It is a strong predictor for functional status later in the disease progression. The severity of the Rheumatoid Arthritis (as judged by functional status) is an even more accurate predictor of future disability than is the duration of the RA.

Believe it or not, poor functional status is even useful for predicting (long term) mortality in Rheumatoid Arthritis. I don’t point that out to scare you, but only to explain why researchers confirm how critical functional status assessment is to your treatment. It is vital to discuss your functional status with your doctors. It is an essential part of your care.

What should we do? We should carefully fill out any forms which our doctors provide which ask for details about what kinds of tasks we can do and how difficult it is to perform them. We can also compare that to what we were able to do in the past (for example, one year ago or before we changed medications, etc). We can even provide our doctors with 2 short lists:

1) Tasks which we can currently accomplish, indicating level of difficulty, or amount of medication required to do them;

2) Tasks which we can no longer perform.

On a less serious note, this reminds me so much of those kindergarten report cards for little tasks: She needs help to tie her shoes; she feeds herself neatly; handwriting is barely legible; cleans up well, but needs encouragement. Let’s hope ours also says: shares and plays well with others.

NIH citation Rheumatology journal abstract

How is Rheumatoid Arthritis Diagnosed? Part 2

Will I need a Patient Protection Plan?

Diagnosing Rheumatoid Arthritis is not easy. Living with RA is no picnic either. And writing about it is like untangling cooked spaghetti.

There is no single definitive test which has a clear positive or negative result for Rheumatoid Arthritis. But, I believe that the diagnostic process could be improved. And perhaps our collective effort will bring us closer to that goal.

First, is there anything that could make diagnosing Rheumatoid Arthritis any faster or less tricky? Is there anything that the American College of Rheumatology could do to improve RA diagnosis procedures? Second, what can we patients do?

Let’s talk about the guidelines (see Part 1). Many patients approach a rheumatologist with symptoms which do not initially satisfy the clinical requirements for diagnosis. Then, within a few months, these same patients are diagnosed with Rheumatoid Arthritis. Do we say that the patients should have had more obvious RA symptoms sooner or that the guidelines should be adjusted?

Look at one scenario: a patient presents with symmetrically inflamed knees, shoulders, and feet. She could easily fall outside of the guidelines because her hands are not yet affected. Hands and wrists are key to diagnosis by today’s guidelines. Many doctors do recognize the feet as equal to the hands in importance, but when they do so, they are stepping outside of the guidelines.

A patient can easily have three out of the seven symptoms on the list recognized by a doctor and fail to receive an RA diagnosis (yet) because symptoms develop in a different order in different patients. It has only been in recent years that the ACR has recognized that early diagnosis and treatment is important to alter the disease course. The guidelines were not developed by studying the onset (early stages) of Rheumatoid Arthritis.

Many of the visible symptoms of RA vary by individual and throughout the course of the disease. Many who “start out” seronegative (with a negative Rf test) are later seropositive. External swelling can be either extremely noticeable or very slight. There are even cases in which the arthritis is not symmetrical.

Some of the symptoms included in the guidelines are totally subjective, such as stiffness. Here, the key to getting the symptom documented toward a diagnosis is good communication. I don’t need to tell you about how well some doctors listen. Even if you have found a good one, you’ve heard the dreadful stories.

Fatigue is another highly subjective symptom. It is considered by many authors of books on RA (physicians mostly) to be a hallmark symptom of Rheumatoid Arthritis. However, fatigue is not even on the list of seven guidelines.

I realize that I am raising difficult questions (please see Part 1, paragraph 5). And the answers may not be easy or obvious. Many doctors are already reaching beyond the guidelines now by considering things such as an anti-CCP result, fatigue, muscle weakness, or Sjogren’s syndrome in diagnosis. These indicators are in the books; and they are part of most RA patients’ lives. The fact that many doctors go beyond the guidelines to look at extracurricular symptoms is proof to me that the guidelines need to be updated.

As I said in Part one, the “listening” problem has been solved with the internet. Doctors do not even need to listen well to patients to improve their understanding of us. The ACR can hire researchers to analyze and compare narratives of many thousands of RA patients who have used the internet to document their onset and diagnosis of Rheumatoid Arthritis. Perhaps, patterns would emerge which could enable doctors to more easily recognize the onset of RA.

What can patients do? If we are unsure of a diagnosis, we should ask for more tests. In extreme circumstances, it is even possible to extract fluid from a joint to examine it for compounds typically present in Rheumatoid Arthritis. We can ask that doctors listen carefully and document our symptoms as we report them. We can suggest doctors read some of the volumes of documentation that is available about RA on the internet, written from the patient’s viewpoint.

When the onset of so many is considered atypical, it is my opinion that a mold which does not fit is the thing that is wrong and not patients’ presentations. Why not use every test available to procure a diagnosis of such a complicated and poorly understood disease which has such devastating consequences? Why risk delaying treatment?

I had not planned to write about this for at least another year. I wonder if I can plead temporary insanity for having questioned authority so resolutely. Does anyone ever win fighting City Hall? I hope I will not need a witness pr– no, a PATIENT protection plan for troublemakers.

Of course my opinion is my own. That is part of what a blog is. Some days it’s like trying to untangle cooked spaghetti. Messy.

The UK's "Campaign Against Ignorance" of Rheumatoid Arthritis

Studies show that people do not understand very much about Rheumatoid Arthritis. There are many misconceptions. But, you probably already figured that out on your own.

In the UK, the National Rheumatoid Arthritis Society is trying to change that. They have an entire campaign about it. They call 2009 the “Year of Rheumatoid Arthritis.”

The director of the NRAS said that they were shocked at the “alarming ignorance” about RA. People do not realize what the symptoms are or who gets Rheumatoid Arthritis. They confuse it with Osteoarthritis a.k.a. “regular arthritis” or OA.

There is also confusion about the seriousness of the risks involved in RA, such as heart disease. It is not seen as a systemic disease. People do not recognize how it brings suffering and disability.

When I first heard about this “Year of RA,” I told friends it was the “coolest thing since ice cream.” I even sent a link out in an email. It was proof of what I knew by experience – and it’s always good to be validated.

I told one rheumatologist about the UK campaign and he called it unnecessary. He said, “I don’t think people are confused about RA. They know enough.” At the time, I was too shocked to reply.

But now I realize that it was a clue to our predicament. That same guy did not approve of using the internet to research RA. (I had given him a printout of the UK NRAS campaign article.) I guess he felt like knowledge is dangerous.

He is not worried about whether people understand Rheumatoid Arthritis. He does not encourage patients to learn more about RA. He does not approve of passing around printouts from the internet. He has never read an RA blog. He is ignorant of the ignorance.

But ignorance is not harmless. Ignorance of Rheumatoid Arthritis is especially dangerous. People who are already affected may not be able to receive the support that they need. Others may not receive an early diagnosis due to ignorance of the disease.

The UK campaign also seeks to encourage early treatment of Rheumatoid Arthritis. That is the only key we know which may help curb damage. People do not seek treatment if they do not know what RA symptoms are or that it is a serious life threatening disease.

So here is our situation: most people do not know what RA is. But, we know a lot about it. We need to speak up. We need to declare war on ignorance just like they are in Britain. We cannot wait for the medical professionals to do it for us. Some of them may be satisfied with the status quo.

NRAS study RA poll and Year of RA

It's Ok to Laugh if You Have Rheumatoid Arthritis

Life with RA can still be funny.

Funny things happen every day. I can laugh at almost anything. It just takes a certain perspective.

Sometimes my son doesn’t appreciate my joking so much about the RA. If I make a funny comment about how bad it is, he might look at me pleadingly and say, “Mommmma, that’s not funny!”

“Yes it is,” I told him recently. “It depends on your point of view.” I always talk to my sons in terms of sports analogies, so I talked about how hard it is to tell whether or not someone stepped out of bounds when you are sitting at the other end of the field. Point of view is everything.

My son loves me so much. He was young when I “got sick” with Rheumatoid Arthritis. He wrote me a note about how mad he was at this “evil disease.” I will always cherish that.

He went with me to my very first rheumatologist appointment. But he stayed in the waiting room. He did not see how rudely I was treated. The man typed on a laptop without looking up at me. He never looked at me. He talked while looking down at his keys. Eventually, he and his laptop escorted me to the door.

Of course, we reported the episode to the family in the car on the way home (two of my kids had been in the room with me). Years later, we were laughing about the incident with a friend who also has arthritis (both RA and OA). She had had the exact same negative experience with Dr. Laptop! Neither of us had kept him as a doctor.

My son heard us recall the story and offered to me his reaction: “You know the world could be a lot nicer if doctors would treat people right.” I think my son was calling a penalty on Dr. L. From his view anyway, the man was out of bounds.

And then, my son laughed out loud, “You know what, Momma? I think maybe the guy was playing video games on his laptop the whole time. He just never looked up because he didn’t want to stop. And he did not want you to see what he was really doing.”

We laughed. That’s very amusing, son. See? You can find the funny side to anything. You just have to look for it.

Dr. Dolittle and Rheumatoid Arthritis

Who is Dr. Dolittle?

I saw this great article on Facebook about how much people with a chronic illness need doctors who will listen. Mainly people with RA read that page, I think. How could we get doctors to read it, I wonder?

Something funny occurred to me when I read it. I hope you get a smile out of it, too.

My kids were watching the old musical Dr. Dolittle. It’s the one with Rex Harrison and the cute pushme-pullyou animal which looks so much like one – no, two - of my mom’s alpacas. I know it’s old, but still delightful.

So Dr. Dolittle decides to become an animal doctor because he can’t get along with people, who he finds hypocritical and pretentious. He sings, “Why can’t people behave more like animals?” Of course, he means humble and honest and kind.

Well, later on, I was reading the article (When You Talk – Does Your Dr. Listen? Link below.) and this strange thing happened: Somehow the movie and the article merged into one. I had to laugh out loud. The song changed into, “Why can’t doctors behave more like people?” Of course I meant more humble and patient and kind.

I guess it was so funny because I still had the British accent and the music in my head. I could just hear Gubgub the pig squeal to get away from some rude and insensitive doctor the way he did in the movie when Dr. Dolittle said he’d consider eating ham again someday.

I know there are some very good doctors just as there are some good politicians and IRS agents. I don’t mean to offend any good doctors. Just the ones who might call themselves “Dr. Do Very Little.” So sorry. But, we are in pain, so we need to laugh every chance we get. Hope that’s ok.

The article really is great, seriously. The comment section is also quite useful. I would definitely consider printing a copy of it to share with friends – and your doctor.
Facebook article link