I am woman

This week a number of events have occurred that have made me reflect on the position of women the in world, and specifically, women in medicine.  I have also come across a report detailing the poor position of women in the New Zealand science landscape, a write up on sexism in the saturday paper, and, on the upside, a rocking pop song challenging for gender equity from a saudi-born songstress!game-370c1170f602ca931f7e8d95fa112ba0

This week I  have I personally experienced four instances of sexist attitudes from medical colleagues, men that I respect highly as colleagues and people.  These have left me feeling disappointed and angry.  Luckily all I have experience is words. A surgical registrar (resident) in Melbourne was propositioned for sex at work and senior female colleagues have publicly suggested that next time she, or others, should acquiesce for the sake of her career.  Outrageous.

Growing up my parents told me I could do anything, a message backed up by TV adds, posters, and if my memory serves me right, I even had a T-shirt.  Girls can do anything.  It was the 80’s and the 70’s feminism wave was still rolling.27921-atl

I set goals, I made a plan, I worked my way through and achieved what I aimed for.  The journey to becoming a  consultant rheumatologist was challenging but manageable.  I was never thought on the way through that my gender disadvantaged me at all.  I now juggle a family with clinical and academic work.  It’s crazy at times but I wouldn’t have it any other way.

This week, my personal appearance has been commented on twice, both complimentary but non the less, quite irrelevant to, and in, the workplace.  I was too surprised on both occasions to make any meaningful reply, but I have a witty yet terse reply ready for the next one.  Describing the other instances would potentially embarrass my colleagues and I respect them too much to do that so will not detail them here.  Both left me clearly understanding that the underlying and perhaps unconsicous attitude to women in the medical workforce left much to be desired.

Well over half the medical undergraduate students I teach are women and we will be most of the workforce in the future.  I hope with increasing numbers of women doctors these attitudes will have to change.  I have resolved that I will not continue to tolerate expressions of sexism in the workplace, or elsewhere for that matter.  Each of us contribute, with the balance of how we contribute depending on the professional and personal roles that we fulfil.  I am woman, I will roar.

Things you learn when you think you know it all

I had planned my second post  to be my story of becoming a rheumatologist, it seems its not to be.  I’ll save it for another post but its definitely on the list, since it formed the inspiration to start 2xrheum. I was reflecting this morning on the American College  of Rheumatology Annual Scientific meeting in Boston a couple of months ago.  As always a fabulous meeting to keep up to date on the developments in rheumatology, interact with colleagues and generally immerse oneself in rheumatology for five days.   My programme was full to the brim and I passed up on Joel Kremer and Michael Weinblatt speaking on “Clinical issues associated with use of methotrexate”.  These guys were graduating from medical school about the time I was born and published the early controlled trials on use of methotrexate in rheumatoid arthritis (here and here).  I had heard Michael Weinblatt speak on methotrexate in New Zealand over 10 years ago.  I still recall some aspects of his talk and use those learnings in my clinical practice.  I  couldn’t begin to estimate how many patients I have treated with methotrexate and consider that I have an excellent working knowledge of the drug.


So what more could I learn? First I learnt that use of technology can provide as good, if not better, learning experience that traditional lectures.  I didn’t make it to the session in person, I listened to the MP3 and annotated the PDFs of the slides in the plane on the way home.  I could pause, rewind, re-read, note to check a reference later – all very useful in cementing in the knowledge to those neurone.  I also keep the annotated PDFs in Evernote, so they are available to me at anytime, anywhere.  Useful for quick refresh in clinic or to email to a colleague the next week.

Second I learnt that eminence still has something to offer beyond the evidence.  All rheumatologists are aware of the data around use of methotrexate, use of supplemental folic acid reducing gastrointestinal side effects and incidence of transaminase elevation.  In the six studies contributing to this Cochrane review, four use folinic acid in at least one of the interventions arms.  I have occasionally used folinic acid for rescue in the setting of cytopenias (fortunately only a couple of times, and not due to my prescribing!) but rarely have I used it in settings of methotrexate intolerance.   Joel Kremer endorses this strongly as useful in his practice, recommending Folinic acid 5mg 8-24 hours after methotrexate with increase dose if required.  Armed with this I have tried this in a patient this week, where change to subcutaneous administration, increasing oral folic acid dose and reduction in dose have only been partially helpful in reducing intolerance.  I’ll let you know how it goes.  So despite the evidence, it took eminence for me to incorporate this approach into practice.

Thirdly I learnt that there are always new data that can influence practice – a recent paper in Annals of the rheumatic disease demonstrates that the oral absorption of methotrexate plateaus out at a dose of 10mg.  This supports the concept of split dosing of methotrexate with say a 20mg dose delivered as two 10mg doses 12 hours apart.  I’ve tried this in a patient who cannot tolerate 25mg in a single dose, doesn’t want other DMARDs and won’t try sub cut.  I haven’t reviewed her yet but I can see that CPR has dropped from mid 30’s, where it has been for ages, to less than 5.  Again I’ll update as new info to hand.

Interesting also to me that while learning, I can learn about learning!  I am taking on a new teaching role this year with undergraduate medical students,  teaching chemical pathology.  I am developing the teaching material, which is both lectures and online learning modules.  I expect to learn a lot about teaching and learning so will also share some thoughts on this blog.

Anyway, thanks for checking in, for the first time or again.  The long absence is between first and second posts is explained (although not excused) by Christmas madness followed by our summer holidays.  New Zealand is increasingly following the Europeans with loads of things shutting down over the summer, as did this blog.  I am forfeiting the visual appeal of the post by posting with minimal images and getting it posted.  Forgive me and use your imagination!

I am now back in the office and  firing on all cylinders.  Or as my Irish friends sometimes say “Sucking diesel” (I’ll leave you to google that as my university is blocking the site – promise it is SFW – not nudity or profanities – a farming reference!)

He pai ake te iti te kore (A little is better than none!)

Ka kite ano


A rheumatology blog is born



This blog was conceived on Twitter. The gestation has been short. Like a baby, it should bring a sense of connectedness, purpose and joy. Let’s hope we avoid loss of sleep, frustration and those little piles of puke you sometime find on your shoulders!

I have been contemplating starting a blog for months . After a light bulb moment while teaching medical students, I drafted a post and got excited………


Paul Sufka then kindly wrote a blog post about starting a blog almost entirely for my benefit. However months passed, other priorities yelled louder so the thought of starting a blog was shelved. At the “Social media bootcamp – blogging” session at ACR 2014 in Boston, Philip Gardiner laid down the challenge. Philip pointed out that, as of November 2014, he was not aware of any female rheumatologists who had a blog.


Eimear happened to be following the twitter feed #ACR14 and tweeted to the effect she was interested in blogging. Negotiations began, via twitter, then email, then Skype and here we are now, 2xrheum. Sharing the work removed barriers along with practical help from twitter friends like Paul Sufka (big ups to you Paul).

So, back to that light bulb moment. Picture a beige windowless seminar room, the likes of which I suspect exist in any university in the western hemisphere.   The medical students were finding seats for the “Introduction to Rheumatology” tutorial that I give every five weeks.  I commented to two  that I had enjoyed having them sitting in with me in clinic earlier in the week. For some reason I followed up with “Whatever you choose to do in medicine, make sure its something that gives you joy.” The hand went up “Why did you choose Rheumatology?” So I answered.

Now, I’ve told this to many people before, including groups of students. People are usually quite interested but his time the students were fascinated. Dissecting each sentence, perhaps to find meaning for their journeys. I can only hope. For me, a lightbulb moment. I had something to say that really meant something to someone else.

So that brings us to here. Together Eimear and I are launching “2xrheum”, a blog collaboration between two female rheumatology doctors. I (RG) am a consultant rheumatologist in New Zealand. Eimear is a specialist registrar in rheumatology (resident, for those of you in US of A) in Northern Ireland.

Whenever I am managing a new professional relationship, whether it be with students, resident staff and even patients, I try to ensure that expectations are understood. What can you expect from us?

  1. We aim to post at least once a month. Not ambitious I know, but achievable.
  2. Our intended audience is rheumatologists and rheumatology trainees (registrars and residents) but we hope that our musings may be of interest to people with rheumatic diseases, other doctors and students.
  3. Our blogs will focus on aspects of our professional lives, sometimes quite peripheral, that we think may be interesting – rheumatology, teaching, research, social media and technology, academic life, leadership and governance. I have been warned that content is the biggest challenge but I have a long list already so let’s see.
  4. We also envisage guest posts relatively frequently.

It’s been said before, write only for two people, so this one’s for Eimear and myself, to remember why we started; because there are people who are interested. Anyone who meets me quickly realises that there’s not much I enjoy more than a good conversation. From our lengthy email and Skype conversations, I have concluded that Eimear and I share this trait! I hope our blog is more than just an outpouring of our inner thoughts. Please leave a comment, perhaps tweet us a message, let’s have a dialogue.

So, thanks for attending the birth of our blog and see you again soon. Perhaps you’ll be interested to hear why I became a rheumatologist.

From Rebecca, Ka kite ano and Eimear, Slán go fóill

(Ka kite ano  – “Car key-tay ah-noh” “See you again soon” – NZ Māori farewell)

(Slán go foil Irish meaning “goodbye for now”)