The CRAJ is online! You can find us at: www.stacommunications.com/craj.html

Volume 17, Number 4 • Winter 2007

The Journal of the Canadian Rheumatology Association

FOCUS ONCommunications in Rheumatology

EDITORIALCryptic Communication

PRESIDENTIAL AND VICE-PRESIDENTIAL GREETINGS

IMPRESSION AND OPINIONDr. Duncan Gordon and The Journal of RheumatologyDr. Barry Koehler: Founding The Journal of the Canadian Rheumatology AssociationDr. Steve Edworthy: The Canadian Rheumatology Association WebsiteUpdate on the Future of the CRA WebsiteDoctor Video: A Guide to Electronic Medical Specialists

NORTHERN (HIGH)LIGHTSMilestones: Dr. Harold Fireman

JOINT COMMUNIQUÉSt. Michael’s Hospital: The ACPAC ProgramCAPA on the MenuMSK Boot CampPracticing Rheumatology in Quebec: Portrait of a Solo PracticeRegional News: Winnipeg, Manitoba, Trois-Rivières, Québec

Victoria, British Columbia

HALLWAY CONSULTDr. Peter Lee: Raynaud’s Phenomenon

JOINT COUNTAssessing Medical Publications

Mission StatementThe mission of the CRAJ is to encourage discourse among the Canadian rheumatology community for theexchange of opinions and information.

CRA EDITORIAL BOARD

Copyright©2007 STA HealthCare Communications Inc. All rights reserved. THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION is published by STA Communications Inc. in Pointe Claire, Quebec. None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means (electronic, mechanical,photocopying, recording or otherwise) without the prior written permission of the publisher. Published every three months. Publication Mail Registration No. 40063348. Postage paid atSaint-Laurent, Quebec. Date of Publication: December 2007. THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION selects authors who are knowledgeable in their fields.THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION does not guarantee the expertise of any author in a particular field, nor is it responsible for any statements by such authors. The opinions expressed herein are those of the authors and do not necessarily reflect the views of STA Communications or the Canadian Rheumatology Association. Physicians should takeinto account the patient’s individual condition and consult officially approved product monographs before making any diagnosis or treatment, or following any procedure based onsuggestions made in this document. Please address requests for subscriptions and correspondence to: THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION, 955 Boul. St. Jean, Suite 306, Pointe-Claire, Quebec, H9R 5K3.

The editorial board has complete independence in reviewing the articles appearing in this publication and isresponsible for their accuracy. The advertisers exert no influence on the selection or the content of materialpublished.

PUBLISHING STAFF

Paul F. BrandExecutive Editor

Russell KrackovitchEditorial Director, Custom Division

Maeve BrooksManaging Editors

Mandi WatsonAssociate Editor

Dana WittenbergerEditor-proofreader, French

Donna GrahamProduction Manager

Dan OldfieldDesign Director

Jennifer BrennanFinancial Services

Robert E. PassarettiPublisher

EDITOR-IN-CHIEFGlen Thomson, MD, FRCPCFormer President, CanadianRheumatology AssociationAssociate Professor,University of ManitobaWinnipeg, Manitoba

MEMBERS:Ken Blocka, MD, FRCPCBurrard Health BuildingVancouver, British Columbia

Michel Gagné, MD, FRCPCPolyclinique St-EustacheSt-Eustache, Quebec

James Henderson, MD, FRCPCChief, Internal Medicine,Dr. Everett Chalmers HospitalTeacher, Dalhousie UniversityFredericton, New Brunswick

Joanne Homik, MD, MSc, FRCPCAssistant Professor of Medicine,University of AlbertaEdmonton, Alberta

Sindhu Johnson, MD, FRCPCClinical Associate,Division of Rheumatology University Health Network-Toronto Western Hospital SiteInstructor,University of TorontoToronto, Ontario

Majed M. Khraishi, MD, FRCPCMedical Director,Nexus Clinical ResearchClinical Professor of Rheumatology,Memorial UniversitySt-John’s, Newfoundland

Gunnar R. Kraag, MD, FRCPCPresident, Canadian RheumatologyAssociationProfessor of Medicine,University of OttawaThe Ottawa HospitalOttawa, Ontario

Diane Lacaille, MD, FRCPCAssistant Professor of RheumatologyRheumatology DepartmentUniversity of British ColumbiaVancouver, British Columbia

Barbara A. E. Walz LeBlanc, MD, FRCPCHead, Division of Rheumatology,Credit Valley HospitalMississauga, Ontario

Janet Markland, MD, FRCPCClinical Professor, Rheumatic Diseases Unit Royal University HospitalVisiting Consultant, Saskatoon City HospitalMedical Staff, St. Paul’s HospitalClinical Professor, University of SaskatchewanSaskatoon, Saskatchewan

Eric Rich, MD, FRCPCStaff, Centre Hospitalier de l’Université de Montréal (CHUM)-HôpitalNotre-DameAssistant Professor, Université de MontréalMontreal, Quebec

John Thomson, MD, FRCPCVice-president, Canadian RheumatologyAssociationStaff, The Ottawa Hospital–Civic CampusTeacher, University of OttawaOttawa, Ontario

Lori Tucker, MDClinical Associate Professor in Pediatrics,University of British ColumbiaFaculty, Centre for Community Child Health ResearchDivision of Pediatric RheumatologyBritish Columbia's Children's HospitalVancouver, British Columbia

Michel Zummer, MD, FRCPCPast President, Canadian RheumatologyAssociationAssistant Professor,Université de MontréalChief, Division of Rheumatology,Hôpital Maisonneuve-RosemontMontreal, Quebec

CRAJ 2007 • Volume 17, Number 4 3

“Hours of waiting in a crowd of similarly

afflicted individuals. Threadbare seats with

cushioning long since crushed to angstrom

thickness by tens of thousands of prior buttocks. One tele-

vision to distract from the ordeal: no sound to accompa-

ny the surreal purple picture on the screen. Staff with no

will to serve with the antiquated equipment at their dis-

posal. Much time to ponder: money could buy a

much-better experience.”

While this cryptic communication could equally well

describe the experience in many hospital emergency

rooms (try it yourself as a civilian sometime), this was a

description written at 35,000 feet on a trip back from

Britain earlier this autumn on a national airline. Proud as

we are of all things bearing national symbols, there is

much that needs renovation in our country.

The CRA over the last number of years has been stalwart

in its resolution to improve professional arthritis care in

Canada. Many projects and persons have been funded by

the CRA to achieve these goals. The CRA over multiple

administrations have been careful stewards of the fund

which was started at less than $5,000 in the early 90s.

The Kraag administration has carried on in this tradition

of diligence. The latest quest to assist another venerable

Canadian institution—The Journal of Rheumatology—has

been considered during long meetings and with considerable

debate. The CRA hopes that it will be possible to keep

Canadian this journal which has long communicated so

many major Canadian rheumatologic ideas to the world.

Communication is the most basic medical skill. From

taking a history to describing the esoteric discoveries in

the laboratory, the ability to relay information in an

understandable and accurate manner is critical. This

issue explores communication in rheumatology from the

peer-reviewed science in Dr. Duncan Gordon’s esteemed

publication through the CRA’s distribution of informa-

tion through print and electronic media.

The Journal of the Canadian Rheumatology Association has

been most fortunate to have had the unrestricted sponsor-

ship of Pfizer to support these efforts. STA Communications

should be commended for their professionalism and

enthusiasm for this ongoing project. Our Managing

Editor, Maeve Brooks, will be on maternity leave presently

and deserves a big Christmas present for her wonderful

and creative work. Paul Brand, the Executive Editor, is the

organizational force behind this publication and will have

a Happy New Year if all our contributors get their articles

in on time! Our new Managing Editor, Mandi Watson, a

seasoned rugby player, fears no rheumatologist: the quar-

terly deadlines will be met!

As this year draws to an end, it is appropriate to thank

President Dr. Gunnar Kraag, VP Dr. John Thomson, Secretary-

Treasurer Dr. Jamie Henderson, and Executive Coordinator

Christine Charnock and all the CRA Executive who have given

great service and leadership throughout 2007.

Merry Christmas, Happy Hannukah, and joyous cele-

brations of all kinds to you and yours. May the New Year

bring some favourable tailwinds and some first-class

service for everyone!

Glen T.D. Thomson, MD, FRCPC

Editor-in-Chief

EDITORIAL

Cryptic CommunicationBy Glen Thomson, MD, FRCPC

Communications are dependent on timing. The editor in Aldershotexploring new techniques in publishing to ensure articles aresubmitted before deadlines!

Editing inappropriate content for the benefit of CRAJ readers whileon assignment at the Vatican Museum.

he holiday issue

of the CRAJ pro-

vides me with

the very pleasant opportunity of

saying hello to everyone and

wishing you all a great Holiday

Season. I hope you all take the

opportunity to make family,

friends and non-professional

activities your priority and take

the time to relax and recharge

your batteries. I might suggest

turning off your e-mail for

14 days. We should be able to

shouldn’t we?

There was sadness in 2007 as

we lost Dr. Adel Fam and Dr. Dale

McCarthy. They were loved and

respected by all who knew them

and had an enormous impact on

patients, students and colleagues.

They will be fondly remembered.

I would like to express my grat-

itude and that of the CRA Executive and Board for the

outstanding job that Christine Charnock does as the

Executive Coordinator of the CRA. She truly is the engine

of our organization. As always our members who serve on

committees, the executive and board of directors contin-

ue to work tirelessly on our behalf and remain the

strength of the organization. They do this while main-

taining their day jobs where their performance isn’t too

shabby either.

The possible purchase of The Journal of Rheumatology

remains a high priority for the CRA and we should have a

proposal to present to the membership no later than our

annual meeting at Tremblant.

Improvement of our website remains a top priority and you

will be hearing of some exciting changes in the near future

from Dr. Andy Thompson. We already have a new server and

will have a much more sophisticated site with enormous

potential such as the ability to provide high-quality video

and web casting. A lot more to come on this so stay posted.

Our Scientific Program remains our jewel and this year

Dr. Alf Cividino has taken over from Dr. Janet Pope as Chair

of the Scientific Committee. The

program looks outstanding so I

look forward to seeing you all at

Mont Tremblant.

In this year’s summer issue of

the CRAJ, Dr. Metro Ogryzlo was

featured; the history of the

Metro A. Ogryzlo International

Fellowship was reviewed and sev-

eral recipients of the Ogryzlo

Fellowship were interviewed. The

award was created by the CRA

with the intention that funds be

raised from members. Such

funding has decreased in recent

years so that less than a third of

the award was supported by the

CRA and the rest by the Arthritis

Society in the last year. TAS will

no longer provide funding so the

award’s future is threatened. I do

not think that this should be

allowed to happen.

It is my objective over the next few months to convince you

that it is important for the CRA to recognize pioneers such as

Metro Ogryzlo and to continue to support this award that

our organization committed to so many years ago.

It will soon be time for another needs assessment and

there is lots of discussion about our meeting sites.

Another Mexican/Canadian meeting looks set for 2011.

We are going to try Kananaskis for our western meeting in

2009 and there is discussion of looking at some

non-skiing venues.

Enough about work! I’d like to get back to the priority

of this greeting. I wish to thank all of you who make the

CRA the success that it is, and as president I order you all

to have a great holiday season.

Till Tremblant!

…………………………………..so it goes

Gunnar Kraag, MD, FRCPC

President, CRA

4 CRAJ 2007 • Volume 17, Number 4

PRESIDENTIAL GREETINGS

Greetings from the CRA President

President Kraag asking not what you can do for the CRAbut what the CRA can do for you!

VICE-PRESIDENTIAL GREETINGS

s I write

this mes-

sage, I am

sitting in my hotel room in

Boston. It is a gray and rainy

afternoon and I am waiting for

the 2007 American College of

Rheumatology (ACR) meeting

to start in earnest. Thousands

of rheumatologists are gather-

ing from all over the world,

coming together to listen, to

talk, to learn, to teach and to

connect. As I reflect on the

past year, since last year's ACR

meeting, I feel continuing sat-

isfaction and continuing

excitement as our specialty

becomes increasingly confi-

dent in its ability to control

inflammatory rheumatic diseases. We are feeling more

and more comfortable with our "new" treatments and talk

of cure and drug-free remission is now commonplace.

This week, we will hear of more novel and exciting treat-

ments. As far as we have come, especially in the past 10

years, I wonder if it is really still only the beginning. What

will things look like 10 years hence?

I'm looking forward to meeting up with Canadian

rheumatologists here in Boston. There is always a good

contingent at the ACR meeting and along with the learn-

ing and teaching and the talking and listening, there will

be laughter and warmth as the Canadian “family” of

rheumatologists connects.

The CRA remains busy on numerous fronts. Under Dr.

Gunnar Kraag’s strong leadership the CRA has continued

to do its usual work and more. Dr. Alf Cividino, our new

Scientific Chair, along with his Scientific Committee has

put together what looks to be another outstanding pro-

gram for the CRA meeting at Mont Tremblant in March of

next year. Dr. Proton Rahman has taken over this year as

Abstract Committee Chair from Dr. Sindhu Johnson and

we are expecting record numbers of abstracts. Dr.

Heather MacDonald-Blumer continues her important

work as Chair of the Education Committee.

Dr. Andy Thompson as

Website Chair has been busy

with major educational initia-

tives about to come to fruition.

Dr. Jamie Henderson, our rock

solid Secretary/Treasurer con-

tinues to watch over the books

with a careful Scottish eye and

offers sage advice on all the

important CRA issues. Our

past president, Dr. Michel

Zummer, continues his impor-

tant work as Access-to-Care

Committee Chair and has

been making certain to con-

tinue to maintain contact and

interaction with our Mexican

colleagues (he has been offi-

cially designated as Minister of

Mexican-Canadian Affairs). Dr.

Vivian Bykerk our Therapeutics Chair has been kept busy

working on updating guidelines and dealing with the

press in such issues as the withdrawal of lumiracoxib. Dr.

Janet Markland and her Human Resources Committee are

busy getting the word out to residents and medical stu-

dents that Rheumatology is “the place to be.” Special

thanks are due to Dr. Arthur Bookman and his “Journal of

Rheumatology” Committee who have been dealing with

the exciting but very demanding issue of the possible

purchase of The Journal of Rheumatology. Of course none of

this work could happen without the person that makes it

all happen, our Executive Coordinator, Christine

Charnock.

As the days shorten, the last of the autumn leaves flutter

to the ground and the north winds grow colder, I would

like to take this opportunity to wish you and your loved

ones a peaceful, restful and rejuvenating Holiday Season.

I look forward to seeing many of you at the CRA meeting

at Mont Tremblant in March 2008.

Sincerely,

John Thomson,

Vice-President, CRA

5CRAJ 2007 • Volume 17, Number 4

Holiday Greetings!

Vice-President John Thomson formally briefing CRA ExecutiveCoordinator Christine Charnock on behaviour at the Harvard Club

The Journal of Rheumatology was founded by Dr. Metro Ogryzlo but you were there from theinception. What were the challenges at the beginningof The Journal and later with the untimely passing of Dr. Ogryzlo?In the early 1970s, Dr. Ogryzlo knew that otolaryngolo-

gists, under the Editor Peter Alberti, founded their own

medical journal that had been quite successful. He was

acquainted with Dr. Alberti which gave him insight into

the world of publishing and hope that this could be done

for rheumatology. Dr. Ogryzlo’s idea was that a journal

could stimulate interest in rheumatology and the study of

arthritis in Canada. This idea of the journal was quite

controversial as, at the time, there were two other major

journals: Arthritis & Rheumatism and Annals of the Rheumatic

Diseases. When these other journals discovered that

Dr. Ogryzlo wanted to found his own journal, they tried to

persuade him otherwise. They promised to be more

accommodating and appoint some Canadian editorial

board members. But this was not Dr. Ogryzlo’s intention.

He wanted to have a journal that would stimulate interest

and work in Canada.

Looking at the hard facts, there were only 200 rheuma-

tologists in Canada at that time. Therefore this couldn’t

only be a purely Canadian journal, the market would not

have supported it. This had to be a Canadian-based inter-

national publication. This would be the only way.

Fifty contributors were invited for the first issue, which

was launched during the 1974 PANLAR Congress. The con-

tributors were international and the editorial board com-

prised worldwide leaders in the field of rheumatology. That

mix continues today: Most Canadian rheumatologists

receive The Journal, while the majority of our subscribers

are from elsewhere: The USA, Europe, Australia, Latin

America, and as far as Japan, Korea and China.

As for the CRA, back in those early days, they did not

understand why The Journal was needed seeing as two

other journals were on the market. The idea was that the

journal in Canada was not necessary but desirable because

it would have a stimulating effect on Canadian rheumatol-

ogy even though few of the articles were written by

Canadian authors. In this fashion, The Journal would have

an international, national and local impact. Dr. Ogryzlo

wanted The Journal to be the official journal of the CRA and

they turned it down, saying it wasn’t the right time.

The challenges at the beginning included establishing

The Journal, fostering interest in potential contributors,

receiving accreditation and recognition from the US

National Library of Medicine so that articles would be regis-

tered. This accreditation was not automatic. In order to

accomplish this, you had to demonstrate that you were wor-

thy of this recognition.

Also, The Journal was financed by 30 rheumatologists

across Canada who made a small investment to get The

Journal off the ground. In this way, we had financial backing,

advertisers, authors and reviewers. In fact, what happened

was our authors became our reviewers, and subscribers

became our authors and reviewers. So you end up with a

loop of quality participants involved in the work of The

Journal. So it is not a one-man band, it’s a group interest-

ed in the academic advancement of rheumatology.

Therefore the challenges were to get readers in rheuma-

tology to buy into this concept and for us to come up with

a good product.

Would you tell us about the stages of publication overa typical month and how much time you spend withyour multiple briefcases in preparing your monthlyedition of The Journal of Rheumatology?We’ve got an office team, we have a Managing Editor and

a whole team of editors. After Dr. Ogryzlo’s untimely pass-

ing, we formed an Editorial Committee that still functions

today, not with the same people but following the same

idea and process.

Dr. Duncan Gordon and The Journal ofRheumatology

Dr. Duncan Gordon is Editor of The Journal of Rheumatology since 1979. He is also a rheumatology consultant atthe University Health Network-Toronto Western Hospital Site and Professor of Medicine at the University of Toronto.

CRAJ 2007 • Volume 17, Number 46

IMPRESSION AND OPINION

CRAJ 2007 • Volume 17, Number 4 7

We meet every two weeks and look at articles, decide

which are worth sending out for review and which review-

ers will review specific articles and which articles will be

published and when. We call this the “hanging commit-

tee,” like the Tate Gallery in London, because we decide,

in effect, which “pictures to hang.”

We typically publish half of the articles submitted, not

necessarily because some articles aren’t good but

because some are merely not appropriate for our journal.

The articles chosen are of course always strengthened by

our reviewers comments, and our editorial board also

comprises rheumatologists with years of experience. So

we survived Dr. Ogryzlo’s passing by benefiting from the

two years he worked hard to establish The Journal and set

this system in place.

The Journal of Rheumatology is one of the best-recognized peer-reviewed publications in the fieldof arthritis. What aspects of The Journal has kept it inthe forefront over the last number of decades? When we started, we were the new kids on the block!

There were three or four peer-reviewed journals and now

there are twenty something. We were unique in that we

were the only rheumatology journal in the world owned

by rheumatologists, which is interesting.

Some of the things we’ve done since we started, of course,

have been copied which is always the case with good ideas.

We’ve always tried to bring controversy to our editorial

pages, I think being provocative is important. We want to get

people thinking and to say what they mean and mean what

they say. We often run cross editorials where we showcase

different view points. We also had our letter section which

often included reader complaints or opinions, so we often

get a crossfire going there as well. At the time we launched,

this was new and different and gave us recognition. We’re

also very user friendly and we do our best to be fair.

While I think we have a high-quality and innovative

publication, we always knew we would never have the

same impact as Arthritis & Rheumatism or the Annals of the

Rheumatic Diseases. These journals publish criteria for var-

ious diseases, articles which get much cited. Our ambi-

tion was to become an Avis not a Hertz!

With the arrival of the Internet era, there have beentremendous changes in all areas of publication. Howhas the Internet affected peer-reviewed scientificpublications? How has this affected The Journal ofRheumatology?

There’s a ying and yang effect with electronic communi-

cation. The good thing is that it provides instant gratifi-

cation. In the early days, we would send our reviewers a

package by the mail, which included a letter inviting them

to review this article. And so when you receive this in the

mail you typically take some time to think about it. You

don’t just put it in the trashcan. With web-based review

systems, you can quickly respond that you are not inter-

ested and put it out of your mind. So the result is that our

submissions have gone up 30% in the last five years as

everything seems to get done faster with the Internet but

by the same token our reviewers are inclined to decline

reviewing material as everyone is busy. So in that sense

instant gratification means instant rejection!

No doubt the Internet has led to our growth and our

creative growth but it is also much less personalized. But

the Internet is not going away, it is here to stay so we have

to work within it.

Changes have occurred in some scientific grants withnew requirements to publish publicly in a timelyfashion. How will this affect The Journal ofRheumatology and other publications?Yes, what you are referring to is the concept of open

access (OA). There is pressure from some parts of the

planet to have all medical articles “open.” For example,

the United States Congress argues that it pays for

research at the National Institutes of Health (NIH) and

asks why one should pay to have access to this informa-

tion. When Harold Varmus, the Noble Laureate, was head

of NIH, he promoted the idea of open access. He pre-

sented the idea that instead of The Journal being support-

ed by subscribers and advertisers in the conventional way,

it should be supported by authors and research funders.

The author would have to pay to have his article pub-

lished which would be borne by the researcher. Certain

We’ve always tried to bring controversy

to our editorial pages, I think being

provocative is important. We want to get

people thinking and to say what they

mean and mean what they say.

CRAJ 2007 • Volume 17, Number 48

research bodies, such as The Wellcome Trust, stated that

they would not allow the researcher to publish a paper in

a journal unless it was instantly and openly available. The

Journal of Rheumatology remains a subscriber-based

publication, but our editorials and correspondence are

freely available to all website visitors. An author-pays

option is being contemplated. Now I’m noticing with

rheumatic diseases that some pharmaceutical companies

are paying big bucks to have open-access articles pub-

lished. It is definitely controversial. When the Editor of

the Annals of the Rheumatic Diseases, which is the best-

known journal in Internal Medicine, canvassed sub-

scribers and asked if they would still subscribe to the

journal if it was open access, the response was a resound-

ing “no.”

The other role player is the advertiser. The advertiser is

invested in the print version as they don’t know how to

measure the impact of online advertising yet. Some journals

give away their content for free and have suffered financial-

ly due to it. The Journal of the American Medical Association was

doing this for a long time and lost a ton of money and have

since stopped. The Canadian Medical Association Journal, an

open and free-access publication, is heavily subsidized by

advertising. If you look at a copy of that journal, a large pro-

portion of pages are advertisements. The leading medical

journals like The Lancet don’t buy into this idea, but I do

believe The New England Journal of Medicine will be making

their articles accessible within six months of publication.

So how this will affect The Journal of Rheumatology is a

work in progress. We don’t know the answer quite yet.

Will there be a change in the role of peer-reviewedscientific publications in the next decade?As research advances, the need for better understanding

will require a wider scope. There are all kinds of areas of

study and so I think the role will not change but increase.

It will be more of the same I think. I think The Journal of

Rheumatology, and other medical journals like it, have an

important role to play in what we call the medical discov-

ery cycle. Scientific publications have a responsibility to

ensure that what is published serves our patients and

society. Because our society is becoming more reliant on

techonology, we need to be especially transparent in the

conduct, sponsorship and publication of scientific

advances. The trust we establish with our readership must

be earned and maintained through such actions.

The idea of the peer-review process affects every level of

scientific publishing: the decision to fund a grant, main-

taining accountability, having submitted materials reviewed

and receiving and publishing Letters to the Editor.

These are not the only challenges we face. Reviewers

sometimes try to protect their “turf” by delaying the pub-

lication of an article and will sit on the information.

There is also misconduct by authors who can fake data or

have duplicate publications.

Taking all this into consideration, peer-reviewed scien-

tific publications have to maintain a steadfast role in the

face of these challenges.

Will there be a change in the way that scientificjournals are published? Do you foresee a day when alljournals are electronic and that the “hard copy”edition is a thing of the past?Advertisers have a big role to play in equation as they are

currently unwilling to support the electronic medium.

Recently Elsevier has been trying to garner favor by guar-

anteeing open access to certain researchers but that is

very experimental. People like to read on paper, they like

print. I don’t know what will come of this…journal ipods?

I don’t see this happening in the near future and I don’t

see leading journals giving up their ownership. For exam-

ple, the Massachussetts Medical Society owns The New

England Journal of Medicine and it has been a great money

maker for them. A lot of the journals are owned by med-

ical societies so in that sense the profits role back to the

organization to do good work.

Unless advertisers can measure the impact of online

advertising vs. their print version, this will not happen.

Scientific publications have a

responsibility to ensure that what is

published serves our patients and society.

IMPRESSION AND OPINION

The CRA membership wish to express our sympathy and condolences to our colleague and friend

Duncan Gordon on the recent tragic loss of his son.

Dr. Barry Koehler: FoundingThe Journal of the CanadianRheumatology AssociationDr. Barry Koehler, the founding Editor of The Journal of the Canadian RheumatologyAssociation (CRAJ), is a staff rheumatologist at The Richmond Hospital and Clinical ProfessorEmeritus of Medicine at the University of British Columbia.

You were the founding Editor of the CRAJ in 1992. Whydid the Canadian Rheumatology Association (CRA) feelthat a publication was necessary at that time? Were thereany obstacles to starting the journal?I don’t think there were a lot of obstacles. The concept arose

from the fertile mind of Dr. Paul Davis, President of the CRA

at the time. Given that we were in the process of separating

our annual meeting from that of the Royal College, it

seemed timely to raise the profile of the organization. We

had a lot of support and published the journal through

STA HealthCare Communications Inc. with the help of

Paul Brand. I think it actually developed quite smoothly.

Was there a time when the CRAJ nearly ceased itsoperation? What were the challenges in the early days ofthe publication?Again, the development of the journal occurred in an easy

fashion, probably easier than we deserved! Everything devel-

oped quite effortlessly; people were happy to contribute

material and there was a lot of enthusiasm from the CRA

board. From my recollection this was a smooth event.

Fortunately, there were no big problems during my tenure.

The CRA separated from the Royal College in 1994 with thefirst Annual Meeting at Mont Tremblant in February 1995.Did the establishment of an in-house publication have insome small way a role in the spirit of independence that ledto the development of the “new CRA?”I don’t think many rheumatologists related strongly to the

CRA as a professional association. While most

rheumatologists belonged to the CRA and attended

meetings, it was not regarded as a very important

organization. I think, in fact, that most rheumatologists saw

The Arthritis Society as serving their needs and taking on

the role of an advocate for rheumatology. For a number of

reasons I think this shifted and, compared to the 1960s, 70s

and even early 80s, rheumatologists didn’t feel as well

represented by The Arthritis Society. Add to that the fact

that we were now breaking away to form an independent

new scientific journal, I think the journal played an

important role within the membership and in the creation

of a new version of the CRA.

The CRAJ continues to publish quarterly in a hardcopyformat. It is available through the CRA website in anelectronic version. Will there continue to be a role for aprinted version of the CRAJ? Do you see the time whenthe publication is strictly electronic?I think it is going to follow the path of most other journals.

My suspicion is that it may well become a solely electronic

medium just because of cost and efficiency. It hasn’t hap-

pened yet but maybe in 10 years it will. I think younger read-

ers will be very comfortable using an electronic medium.

When they get to my age they’ll probably be expecting that

because it’s convenient. You start to wonder why we are using

all this paper, it’s expensive and so on. For the most part, I

think people are going to be ready to use electronic versions.

It also makes sense in terms of storage. If you want to refer to

an article written two years ago, the likelihood is that you

won’t have that journal lying around. You look it up online! I

think accessing this publication online makes sense.

Do you have any thoughts on the future direction of theCRAJ?I think Dr. Glen Thomson has really moved this publication

along very nicely. He has organized it very well with some

political content, some history and some science. I think the

CRA is focused on the science more now with their work on

guidelines and research. I think the journal content

includes a nice balance. I doubt that anyone would want to

see the journal become a purely political vehicle so balanc-

ing this is good. It’s a successful format. I continue to pick it

up and read it. I suspect most members feel this way; it’s not

regarded as a throw-away journal.

CRAJ 2007 • Volume 17, Number 4 9

CRAJ 2007 • Volume 17, Number 410

Dr. Edworthy is a staff rheumatologistat Foothills Medical Centre andAssociate Professor of Medicine at theUniversity of Calgary.

There are few organizations today thatdo not have a presence on the Internet,yet when you launched the firstCanadian Rheumatology Association(CRA) website this was very novel. Wouldyou tell us what led the CRA to launchthe website when it did? What obstaclesdid you face?You are correct in noting that when the

CRA was developing its website in the mid-1990s, there

weren’t many examples to follow of not-for-profit medical

organizations developing their own website. Our biggest

challenge was raising the website concept to a priority

level in the face of many other competing ideas.

Fortunately, the executive recognized the need to establish

a good electronic environment from which to publish

CRA information to members.

We were restricted by the types of software and hard-

ware we could use, which meant a greater technical

expertise was required to manage our site at that time.

Another obstacle was that the CRA leadership had ques-

tions about the value this would have for its members. For

example, would members want to go to the Internet when

they could get their information via mail? Also, there were

some fears that the information might be in some way

misconstrued or cause unforeseen repercussions within

the medical community as it became available outside our

group. There were also some uncertainties about using a

new technology. Once we had decided to go ahead with it,

we were very fortunate to have Elisia Teixeira take on the

role of “webmistress,” which she continues to perform

today.

The sheer novelty of websites and theInternet has faded somewhat. How mustwebsites evolve to be better sources ofeducational material and information? The Internet is now “business as usual!”

Through the CRA website, we’ve got a great

opportunity for users to share their prac-

tice knowledge through audits of practices,

treatment of patients and presentation of

challenging cases. Those types of interac-

tive activities can now be managed very

effectively with online tools such as

Elluminate®. We are now in a position to

present the type of content that is required

on the web to attract attention: solid medical information

for patients, primary-care practices and rheumatology

colleagues. The work involved in providing this informa-

tion is substantial, particularly having to be presented in

an electronic format rather than print.

Another step is ensuring that there is a more

direct-to-the-consumer approach…the consumer being

the individual rheumatologists, others interested in

rheumatology, patients and even other associations which

are engaged with the CRA.

A major challenge for all websites is being known on the

worldwide web. One has to keep on top of being visible on

search engines like Google™ or you just don’t get found.

Another challenging new Internet direction for physi-

cians is the use of personal health records online. This is

a concern for physicians because they feel it is outside

their realm of practice. But this is definitely a consumer-

driven trend that will be hard for established medicine to

avoid. I’m anticipating that websites such as the CRA will

become interlinked and perhaps become a part of the

personal health record. That’s the direction some of us in

the informatics arena are exploring, with various tech-

nology firms.

Dr. Steve Edworthy: The Canadian RheumatologyAssociation Website

IMPRESSION AND OPINION

CRAJ 2007 • Volume 17, Number 4 11

In your view, how should established journals embracethe new electronic technology? Do established scientificjournals ignore the Internet as their peril?Any journal that cannot provide an electronic source to

their readership is definitely in peril. At this point, all the

students that I work with at the University level rely totally

on the electronic form of articles and I doubt they ever

use paper sources. When they can’t get access to a journal

online, they merely ignore that one.

There are many problems with competing in the elec-

tronic journal world. It’s not a trivial task: there’s a lot of

time and money that needs to be invested, a change in

style and likely a different business model for the produc-

tion of the electronic journal. However, if you take an

established journal with a good track record and do a

good job of moving it into the electronic format, they

have a much better chance of competing in the market.

Organizations like the CRA have limited resources andare increasingly dependent upon advertising to enableand promote education and information. This appearsto be the long-standing trend on the Internet ingeneral. Is this the way that communication inrheumatology and medicine in general should evolve?Are there any alternatives to their “business model?”It’s true that the CRA has limited resources and that

advertising is a mechanism to obtain necessary funds.

That model works but its downside is that it is annoying

to the reader to have that kind of information in their

face. It may be somewhat dangerous also in the sense that

advertising may serve as a conflict of interest with the

educational content being presented, which may discuss

a product or certain classes of drugs.

Many people are looking for an alternative to that busi-

ness model. I can’t say what would work better for the

CRA. Some websites operate on a subscription basis and

charge for membership. There can also be a limit to the

amount of advertising exposure for corporations which

have other values.

There may be a chance for collaboration with other

organizations willing to fund the website or participate in

other activities that do not show on the website but are of

value to the website and the CRA. There are ways to utilize

the Internet that do not draw on advertising dollars. For

example, we are beginning to see clinical trials operating

via the Internet. Performing these trials can be of tremen-

dous value to companies and to society. A well-established

website, with a good track record, could conceivably offer

a service that wouldn’t require advertising but could facili-

tate a more efficient clinical-trial methodology.

There is also potential for an interesting collaboration

with the Canadian Medical Association (CMA). The CMA

has tremendous expertise in a variety of internet-based

services including the provision of patient information,

an “online store” with electronic products that doctors

can purchase. They demonstrate a real interest in helping

doctors’ practices become more efficient. The possibility

of a partnership with such an association for the CRA

would be a tremendous business opportunity. To link

forces with the CMA, which has a much bigger market and

some drivers the CRA doesn’t have, is the best business

opportunity I see for the CRA’s future.

In what direction would you like to take the CRAwebsite in the next five to ten years?In addition to the great work it is involved with today,

under the leadership of Dr. Andy Thompson, I would like

the CRA to become more integrated with our medical

practices. I would like the CRA website to facilitate the

secure exchange of communication and medical informa-

tion between caregivers.

Any journal that cannot provide an

electronic source to their readership is

definitely in peril.

The Internet is now “business as usual!”

Through the CRA website, we’ve got a

great opportunity for users to share their

practice knowledge through audits of

practices, treatment of patients and

presentation of challenging cases.

The CRA website continues to function effectively with

more than 40 visitors a day and more than 15 of our

members logging in each day. We hope to further

improve these statistics with some upcoming changes and

developments.

A new look: We will introduce a slightly-revised page

layout. We are doing this in reaction to the needs of our

members and to allow for more flexible sponsorship

opportunities.

Easier-to-find important content: Our members stat-

ed that they were having some difficulty finding important

information such as meeting dates and new highlights and

programs. To accommodate this we will have a content sec-

tion on the main landing page and get rid of the “ticker

tape” running across the top of the page.

More prominent links: Our other committees wanted

more prominent access to their programs. As such, we will

have areas on the home page with direct links to other

important CRA resources such as The Journal of

Rheumatology!

Changing sponsorship model: Our sponsorship model

is changing for the better. We are now allowing our

sponsors to post their continuing medical education (CME)

programs on our

server. You’ll notice

a clearly identified

“sponsorship sec-

tion” on the right

hand side of the website. By “clicking” on this section our

members will be able to view CME programs provided by our

sponsors. Realizing that some of these programs may con-

tain an inherent bias, all programs in the sponsorship sec-

tion will be clearly identified. The CRA executive feels that

this transparent sponsorship model will be mutually benefi-

cial for the CRA, our membership, and our sponsors.

This is an exciting time for the CRA website as we move

into our next phase of development with the commitment

of promoting the pursuit of excellence in arthritis care,

education and research.

Dr. Andy Thompson & Elisia Teixeira

Dr. Andy Thompson is Chair of the CRA’s Website

Committee and Elisia Teixeira is the CRA’s Website

Webmistress.

12 CRAJ 2007 • Volume 17, Number 4

IMPRESSION AND OPINION

Update on the Futureof the CRA WebsiteBy Andy Thompson, MD, FRCPC, and Elisia Teixeira

The 2007 ACR Meeting in Boston

CRAJ 2007 • Volume 17, Number 4 13

1. Dr. Mario

Game/System: Dr. Mario (Nintendo Entertainment

System)

Skill: Treats only those afflicted with blue, red and yel-

low viruses

Real-world specialty: Infectious Disease specialist who

must be tenured in a University Hospital to have such a

narrow scope of practice and still make a living.

2. The Professor

Game/System: The Legend of Zelda: Ocarina of Time

(Nintendo 64)

Skill: Uses only potions and herbal remedies

Real-world specialty: Practicing medicine without a

license as part of the “alternative medicine” movement

3. Dr. Stiles

Game/System: Trauma Centre: Under the Knife

(Nintendo DS)

Skill: Slows down time to perform surgery

Real-world specialty: Canadian surgeon, the slowing

down time may be the reason we have such long waiting

lists for operations

4. Dr. Robotnik:

Game/System: Sonic the Hedgehog (Sega Genesis)

Skill: obsesses about a talking hedgehog and plans end-

less failed revenges on his foes.

Real-world specialty: Medical administrator on another

delusional quest

Doctor Video: A Guide to Electronic Medical Specialists By Ian T. D. Thomson

What do our children learn about medicine from their omnipresent video games? It is necessary for parentsand physicians to communicate with these young minds so that they understand these video characters in thecontext of what doctors do in the real world.

This quick search for video doctors failed to reveal any practicing rheumatology. When will this obvious omission be

corrected?

Afew years ago, I had

reported in the CRAJ

that Dr. Harold

Fireman had retired. Harold

read the piece while in his

office after his secretary had

brought it to him asking

what they were doing work-

ing if he was retired. He

called and assured me he

was hard at work with no

immediate plans for retire-

ment.

I called him when I

recently heard that he had

retired and he immediately

confirmed that “yes, Gunnar, this time it is true.” I asked

him if he would do an interview and he said he would be

delighted. He asked me how old I thought he was, and

when I hesitated he informed me that he was 88 years old.

At this point he asked to be excused and continue the

conversation another time as he was just leaving for a

scheduled tennis match. I snapped the attached photos

the day after our interview.

I met Harold for the interview and had a number of

questions ready to go, but Harold was well prepared and

started right in. Questions were not required.

He didn’t start on himself, but rather began by talking

about Wally Graham. He recalled that the entire curricu-

lum in Rheumatology was covered by a single lecture

given in less than an hour by Dr. Wally Graham who cov-

ered osteoarthritis, rheumatoid arthritis, ankylosing

spondylitis, gout, and collagen diseases. It was 1940 when

Harold heard that lecture, and he still remembers it as

one of the best he has ever heard. He recalls Wally as

very good looking, slim, and very energetic and restless.

He played the piano, held the Canadian record for the

440-yard dash, and was a supreme motivator. He felt it

tragic that he died suddenly

at the age of 56 years and

was sure that he would have

continued to make major

contributions to rheuma-

tology. He was a strong influ-

ence on Harold in guiding

him to choose rheumatology

as a career.

He also recalled Dr. Almond

Fletcher as one of the leaders

in arthritis, and described

him as a slight, almost

cachectic man who always

looked unwell, but was very

bright. He felt his influence

paled in comparison to Wally Graham. He actually left the

field of arthritis to work with Dr. Walter Campbell who spe-

cialized in diabetes and on making this switch Harold

recalls him saying “don’t hold it against me!” This was at the

time that the first dose of insulin was actually given to a

patient at the Toronto General Hospital.

Harold graduated in 1942 and had a job waiting for him

at the Barnes Hospital in St. Louis, but was stopped from

going because he was needed in the armed forces and

served in the Air Force from 1942 to 1946. He recalls

another physician who was also in the Air Force,

Dr. Metro Ogryzlo and still remembers having dinner with

Metro in Moncton. The food they were used to was most-

ly powdered and he recalls how excited Metro was when

they were served sour pickles—a relative delicacy com-

pared to everything else. He also recounts a story told to

him by Dr. Phil Rosen, who recalled an encounter with a

young physician whom he did not know coming from

another ward and literally grabbing him with excitement

over a case that he had just seen and dragging him over to

show him. The young physician was Metro and that meeting

and relationship led to Phil’s career in rheumatology.

JOINT COMMUNIQUE

Milestones: Dr. Harold Fireman By Gunnar Kraag, MD, FRCPC

14 CRAJ 2007 • Volume 17, Number 4

NORTHERN HIGHLIGHTS

He recalls Phil Rosen telling him that he collected

wooden clocks largely because he felt he should match

his colleague, Dr. Hugh Smythe, who was collecting

Japanese pillows. These pillows were also made of wood.

He interned at the Ottawa Civic Hospital because he

could not go to the United States, as mentioned, and this

is how he subsequently also came to settle in Ottawa. He

did some training in Kingston and recounted many sto-

ries about the infamous Dr. Malcolm Brown, Dr. Russell

Cecil whose text was the best at the time, Dr. Eric

Bywaters, and others. Harold would be a superb after-din-

ner speaker as he is a natural storyteller and his experi-

ences are fascinating.

Interns, in those days, did not get paid except for a

bonus at the end of the year which was about $50. They

were provided with room and board as well as a laundry

service. Harold recalls that a way to make some money was

to donate blood for which you got about $15. Of course

in those days the blood was taken immediately to the

patient and not stored.

Prices were such that he could go to the Fairmont

Château Laurier with a date for dinner and dancing at the

cost of $1.50...so $15 was a lot of money. As a result, he

thinks that he and his fellow trainees were likely quite

anemic.

He received his fellowship in 1961 and, along with

Dr. Henry Sims, started an arthritis clinic at the Ottawa

Civic Hospital. He also built up his practice with patients

who had arthritis since nobody wanted to care for them

as the general feeling was that nothing could be done.

There was no Ontario Health Insurance Plan (OHIP) in

those days and all the hospital work they did was pro bono.

Harold feels that the last 20 years were his best and

most enjoyable. He never minded going to work because

he loved it and never considered it a chore.

As to the secret of his longevity, he attributes it partly to

genetics, but primarily to staying active so his advice to

me was “stay active!” Harold continues to play tennis regu-

larly, he also plays bridge, travels, reads and participates in a

medical history club where he recently made a presentation.

Voltaire didn’t produce his greatest work until he was

67 years old and Harold said his best and most enjoyable

years were from the age of 68 years to 88 years. He loved

what he did and kept active and engaged. The next time I

feel like a nap, I’ll ask myself: “What would Harold do?”

Harold has the knack of holding you a bit spellbound

because he tells a story so well. I wish we had the space to

tell them all.

Congratulations to Harold on a great career!

Dr. Gunnar Kraag, MD, FRCPC

President, CRA

Harold about to unleash his scorching backhand for another win!

As to the secret of his longevity, he

attributes it partly to genetics, but

primarily to staying active so his advice

to me was “stay active!”

15CRAJ 2007 • Volume 17, Number 4

The Advanced Clinician Practitioner in Arthritis

Care (ACPAC) Program is a University of Toronto,

faculty of medicine-based continuing education

certificate program in advanced musculoskeletal

(MSK)/arthritis care for experienced MSK physiothera-

pists and occupational therapists.1 This program was

developed at St. Michael’s Hospital (SMH) in collabora-

tion with The Hospital for Sick Children (HSC) and The

University Health Network, Toronto, and is run with the

help of over 60 faculty members, consisting of both aca-

demic and community healthcare professionals. Preceded

by the practitioner program at HSC,2 this interdisciplinary

health professional program is currently housed at SMH.

This innovative program was developed in response to a

documented need for an interdisciplinary approach in

diagnosing and managing patients with osteoarthritis

(OA) and rheumatoid arthritis (RA).3

The decrease in the number of rheumatologists due to

decline in program enrollment and aging population of

existing rheumatologists has been well-documented.4

There is increasing interest by the Ontario Ministry of

Health to change the current model of care for chronic

diseases and it is mandatory that all members of the

arthritis care team in such a model be appropriately

trained.

The ACPAC program is delivered in an episodic format,

consisting of 10 intensive units (academic and clinical),

offered one week per month. The program is based on

expected competencies and is rigorously evaluated.

The curriculum is based on the integration of material

from five core modules including Basic Science Theory

Underlying MSK Practice (n = 1), Foundations of Clinical

Practice (n = 1), Therapeutic Management (n = 1), and

the Art and Science of Clinical Practice (n = 2).

To date, since 2005, 13 trainees have graduated from

this program; 10 trainees have been accepted to the

2007-2008 academic year. All trainees are accepted

using strict criteria, come from institutions with full support

and a plan to return as practitioners working under med-

ical directives in a team environment. The trainees come

from rural (under-serviced), community non-academic

and academic health centers across Ontario. Evaluation

of the effectiveness of curricular design as well as the

development of new models of care/reintegration process

is ongoing.

The ACPAC program is being offered at a critical time in

the context of rapidly changing healthcare delivery in the

Province of Ontario. As arthritis care givers, we need to

position ourselves at the forefront of developing new and

effective models of chronic disease management.

The ACPAC program was originally developed with the

financial assistance of Amgen/Wyeth (unrestricted edu-

cational grant), Arthritis Society (Ontario branch), St.

Michael’s Hospital and its Foundation. Currently it is also

supported by a three-year grant from the Ontario

Ministry of Health and an unrestricted educational grant

from Abbott.

References:1. The ACPAC Program website. Available at:

http://www.stmichaelshospital.com/programs/mobility/acpac.php. Accessed September 10th, 2007.2. Campos A, Graveline C, Ferguson JM, et al. The Physical Therapy Practitioner: An Expanded Role for

Physical Therapy in Pediatric Rheumatology. Physiother Can 2001 Fall; 53(4):282-7.3. MacKay C, Devitt R, Soever L, et al. An Exploration of Comprehensive Interdisciplinary Models for Arthritis.

Arthritis Community Research & Evaluation Unit (ACREU). University Health Network; April 2005. 4. Hanly, JG. Manpower in Canadian academic rheumatology units: current status and future trends.

Canadian Council of Academic Rheumatologists. J Rheumatol 2001; 28(9):1944-51.

Where graduates were practicing within the province ofOntario in the first two years of the ACPAC program

St. Michael’s Hospital: The AdvancedClinician Practitioner in Arthritis CareProgramBy Dr. Rachel Shupak, Program Director and Dr. Katie Lundon, Program Coordinator

16 CRAJ 2007 • Volume 17, Number 4

JOINT COMMUNIQUÉ

CAPA on the MenuBy Ken Blocka, MD, FRCPC

Ihad the pleasure of being seated next to Ms. Anne Dooley,

President of the Canadian Arthritis Patient’s Alliance

(CAPA) at the windup banquet of this year’s annual meet-

ing of the CRA at Lake Louise. Like many rheumatologists, I

was just vaguely aware of CAPA but had no clear understand-

ing of the organization’s goals and objectives. Any uncertain-

ty I had was quickly dispelled by the enlightening conversa-

tion that transpired between bitefuls of buttery beef.

Anne is a passionate and articulate spokesperson for

CAPA, a patient-driven national advocacy organization

with members and supporters across Canada. CAPA cre-

ates links between Canadians with arthritis and assists

them to become more effective advocates with the ulti-

mate goal of improving the quality of life for all patients

affected by the disease.

Established in 2001, CAPA communicates the latest in

knowledge, research and health policy issues and works

collaboratively with a range of partner organizations

throughout Canada.

CAPA’s strategic priorities include:

• Raising awareness about arthritis to ensure timely and

uniform access to appropriate medications, health

professionals and services.

• To ensure a meaningful voice in arthritis research at all

decision-making levels.

• To create a source of information for adults and

children with arthritis and their support communities.

• And to assist adults and children in obtaining access to

care and reimbursement and other services that may be

required in managing a potentially lifelong disorder.

I was particularly struck by the CAPA premise that the first

expert in arthritis is the person who has it. A self-evident

concept? Perhaps, but one which represents a sea change in

attitude for a profession which has traditionally viewed the

physician as the acknowledged expert and the patient the

compliant supplicant. The realization among patients that

they are both entitled to and capable of providing a valuable

and necessary opinion is no less profound.

I personally have always regarded my relationship to

patients as a partnership and, where possible, have

sought to engage my patients in every aspect of the

decision-making process. I am sure that we have all rec-

ognized how this type of interaction may pay dividends as

far as adherence to care and the overall quality of the

physician-patient experience. We learn from our patients

all the time. No matter how well intentioned and learned

our recommendations may be it is our patients who must

ultimately decide what is best for them.

Whether seated across from their physician, a policy maker,

a pharmaceutical company or a grant adjudication commit-

tee, our patients bring a unique and valuable perspective.

I applaud organizations such as CAPA for promoting

and fostering this perspective and for helping to empow-

er our patients to see themselves as key stake holders in

the battle against arthritis. It is a “win-win” strategy for us

all and CAPA deserves our fullest support.

“Coffee or dessert anyone?”

For information about CAPA please contact Anne Dooley

President, Canadian Patients Alliance: anneme@shaw.ca or

www.arthritis.ca/CAPA

MSK Boot Camp By Joanna Bostwick

Every December for the past four years, Dr. Alf Cividino

has coordinated a four-week “MSK Boot Camp” for sec-

ond-year medical students. As the name suggests, this

specialty elective offers a broad base of opportunity to

learn musculoskeletal (MSK) medicine. The elective is tai-

lored to each student’s personal learning objectives,

which vary depending on their respective interests in

either rheumatology, physiatry, family medicine or ortho-

pedic surgery.

A day in the MSK Boot Camp is filled with interactive tuto-

rials or group lectures, clinical skills in MSK physical exami-

nation, and special procedures such as joint injections. As

18 CRAJ 2007 • Volume 17, Number 4

JOINT COMMUNIQUÉ

CRAJ 2007 • Volume 17, Number 4 19

well, students are assigned to a variety of different clinics

each week to gain hands on experience with complex

rheumatologic cases. For one of the four weeks, students

are part of the in-patient rheumatology service, which

gives medical students exposure to management of

patients assigned to Internal Medicine. Weekly rheuma-

tology and orthopedic radiological rounds add to the

understanding of disease presentation and severity.

There is a real sense of collegiality and support

amongst the Hamilton rheumatologists. The students

meet weekly with the group at rheumatology rounds and

share their experiences, thereby gaining valuable experi-

ence presenting and interpreting case studies. On two

separate occasions, students delivered a 45-minute pres-

entation to the doctors. Although initially nerve wrecking,

the experience was monumental to help students gain

confidence in applying their knowledge base and to be

able to face challenging questions from our preceptors.

My personal experience has been very rewarding, and in

many respects, life changing. I have had a long-standing

interest in musculoskeletal medicine, an interest that devel-

oped while studying kinesiology at the undergraduate level.

While I initially enrolled in the MSK Boot Camp elective

simply out of this interest, it turns out I got more out of it

than I ever could have expected. In my first week of “boot

camp,” I met a young man who had a near death experience

with Wegener’s granulomatosis, an elderly patient crippled

by rheumatoid arthritis, and a young woman struggling

with Lupus. All three suffered from serious rheumatologic

diseases, but yet maintained a positive spirit and a sense of

humour that I found truly inspiring.

The rheumatologists working with the “boot camp” stu-

dents have been great teachers. Everyone I have met has

been friendly and incredibly passionate about his or her

field. In my personal experience, I have found the level of

support and encouragement from the physicians to be

quite inspiring. One case that particularly stands out in

my mind is that of a young father who had recently been

diagnosed with Ankylosing Spondylitis (AS). He was

eagerly waiting approval from the government for the use

of a Biologic drug, as he did not have a drug plan that

would cover the high cost of this treatment (which is very

troubling, as studies have shown that early management

in AS can significantly improve prognosis). Although it

must be quite frustrating for physicians to deal with the

fact that the high cost of medication can sometimes limit

treatment options, it has been wonderful to witness the

level of advocacy rheumatologists have shown for their

patients. The satisfaction of helping people control serious

health problems over a long period of time and the reward

of developing genuine long-term friendships with

patients in the process has been the most attractive

aspect of a career in rheumatology.

Upon reflection, rheumatology provides a wonderful

blend of basic physical examination and the rapidly

expanding science of immunology. I enjoy the challenge of

diagnosing patients and trying to understand the patho-

physiology of autoimmune and inflammatory diseases.

While at the MSK Boot Camp, I quickly realized that the

field of rheumatology offers a number of interesting career

opportunities allowing practitioners to tailor their respec-

tive practices to their personal interests and to constantly

learn new things. And considering that the root causes of

so many diseases remain unknown, rheumatology is a field

that is ripe with potential in terms of further advancement

and future research. This is what draws me to rheumatology:

the patients, the independence, and the learning.

There is a sense of excitement about the pace of scien-

tific progress in this field and the likelihood that this

progress will translate into new practical therapies for

people with rheumatic diseases. With a nationwide short-

age of trained rheumatologists and an increasing burden

of MSK diseases in our currently aging population, I

sense that a career in rheumatology would allow me to

balance my personal life with the challenges that rheuma-

tologists will be faced with in the near future.

From left to right: Dr. Cividino and McMaster University’s 2008Michael G DeGroote School of Medicine graduating students whoparticipated in the MSK Boot Camp: Nadine Gebara, JoannaBostwick and Hinal Sheth.

At first, I practiced medicine as a general practitioner for

four years in Abitibi in Rouyn-Noranda and in Laval at the

Cité de la Santé. Then, from 1984 to 1999, I practiced as a

rheumatologist and internist at the Sacré-Coeur de

Montréal Hospital. I finally set up a solo practice in Saint-

Eustache in a polyclinic where I have been practicing for the

last eight years already. In total, I have been practicing med-

icine for 34 years, including six years of residency!

Why a solo practice after years in a university setting

(hospital affiliated with the Université de Montréal)? First

of all, to be closer to home!

I also made that decision because I wanted to practice

rheumatology on a full-time basis, incorrectly thinking that

it would be less intense. In a clinic with 30 GPs and a very

vast population pool consisting of at least 250,000 people,

from Lachute to Terrebonne and from Laval (North-West

area) to Tremblant, there definitely is no shortage of work!

On the contrary, the practice has become quite diversi-

fied! After several months, requests to participate in com-

mittees, to teach or provide medical consultations and hold

conferences for physicians or the public flowed in. I recently

also received requests to teach preceptorship sessions.

Four years ago, a small clinical research practice was set

up and a nurse clinician was hired on a part-time basis.

Research is mainly focused on genetics (recruitment in

osteoporosis, osteoarthritis and rheumatoid arthritis),

phase III studies (rheumatoid arthritis, psoriatic arthritis,

etc.) and two phase II projects. I also participate in the Early

RA registry of my colleague Murray Baron from McGill.

In my opinion, running a solo practice has allowed me

to have a more flexible schedule and to combine all my

activities. In addition, my participation in the Convention

has increased in the last few years, enabling me to keep in

touch with several colleagues and update my knowledge

in our profession.

During my free time, my wife Francine and I “work” golf

courses in the summer. During the other seasons, we keep

busy by going to the cinema, reading, walking and travel-

ling. Happy grandparents to two grandchildren, we have

also replaced some leisure time with providing “babysit-

ting services”!

To summarize, running a solo rheumatology practice is

still very appealing to me and allows me to spend precious

time with my family and friends.

Practicing Rheumatology in Quebec:Portrait of a Solo PracticeBy Michel Gagné, MD, FRCPC

The most exciting recent news from Manitoba is a positive

report on the human resources front. Winnipeg has now

added four new rheumatologists to the region, bringing our

total to eleven. Dr. Shikha Mittoo joined the academic group

at Health Sciences Centre in July 2007. She trained at Johns

Hopkins University and comes to Winnipeg with a special

interest in pulmonary involvement of connective tissue dis-

eases. Drs. Ramandip Singh and Adarshdip Brar completed

their training in Winnipeg in 2006 and 2007 respectively, and

have become our first husband and wife rheumatology team.

They have established a joint practice (awful pun fully intend-

ed) in the community. Dr. Snezana Barac also completed her

training in Winnipeg in 2007 and is commencing her com-

munity practice once the fellowship exams are completed.

As winter approaches, we remember that we were blessed

with a beautiful summer this year in Manitoba allowing all

of us to pursue our various non-rheumatologic interests.

Dr. Glen Thomson coached some of Canada’s hopefuls for

World Cup 2014. Dr. Dave Robinson canoed with his fami-

ly and trained for the Joints in Motion climb in Peru. Drs.

Tim McCarthy and Christine Peschken filled their summer

days at their respective cottages with their families. Dr.

Carol Hitchon was busy with long-distance cycling. Dr.

Hani El-Gabalawy was involved in an intense cross-training

program getting ready for another hockey season.

Meanwhile, I continued to struggle with my golf game and

trained to improve my time at the Royal Victoria Marathon.

REGIONAL NEWS

20 CRAJ 2007 • Volume 17, Number 4

JOINT COMMUNIQUÉ

Update fromManitobaBy Cory Baillie, MD, FRCPC

CRAJ 2007 • Volume 17, Number 4 21

Since 1999, I have been working as a rheumatologist in the

Rheumatology/Physiatry Clinic for Central Quebec, located

at Trois-Rivières in the Mauricie Region. There are currently

four rheumatologists in our group (Drs. Louise Rouleau,

Michèle Dessureault, Frederic Morin and myself), and we will

soon be welcoming a new recruit, Dr. Clode Lessard. We are

a highly dynamic team, involved in a great number of very

interesting professional activities.

We are affiliated with the Centre Hospitalier Régional de Trois-

Rivières (CHRTR). The trend in rheumatology these days is to

send patients for outside-hospital care, but our group con-

siders it essential to maintain an in-hospital department in

order to treat patients with complex pathologies, such as

severe vasculitis or collagenosis. We are recognized as inflam-

matory disease specialists and are therefore frequently asked

to consult with regard to complex multisystem disorders.

We are all deeply involved in the training of medical

students and residents. Around ten residents rotate

through our clinic each year. We use this opportunity to

fully explain our specialty, and with some success, since a

number of them have subsequently chosen rheumatology

as their subspecialty. In actual fact, I think I was the first

resident to apply for a rotation at Trois-Rivières in 1994. I

am sure they had absolutely no idea that that young

unknown resident would ultimately become a colleague!

In 2005, the CHRTR became a designated medical train-

ing facility affiliated with the Université de Montréal. This

means that students can now take their full medical train-

ing in Trois-Rivières, from pre-med, core medical courses

and clerkship, to residencies in family medicine. All our

department members have lent a hand in the training of

these future physicians in various areas. I would like to

mention Dr. Dessureault’s outstanding input in particular:

she has worked tirelessly on the introduction and supervi-

sion of the first year students’ mentoring program. We are

also happy to welcome rheumatology residents who express

an interest in doing their rotation with us.

As far as clinical research is concerned, we are partici-

pating in several study protocols related to arthrosis,

osteoporosis and, obviously, rheumatoid arthritis. We also

supervise an infusion centre in our clinic. This service has

become necessary because of the growing number of

intravenous treatments now available.

In short, things are really moving in the Mauricie area

and you can rely on our team to maintain the standard

that rheumatology is a dynamic specialty, with close ties

to its community.

News from Trois-RivièresJean-Luc Tremblay, MD

British Columbian rheumatologists have had something to

celebrate this year, as long-standing efforts within the

Specialist society, have finally led to attention to disparity

issues for rheumatology and other disadvantaged groups,

using the MANDI formula, that compares net daytime

income from Monday to Friday between specialities. This

has been the culmination of a long hard fight.

Rheumatology has already had a 17% increase in fees, and

should receive at least another 6%, over the next three years.

This latter amount may increase, depending on the total

amount available for distribution. A fee dispute between the

Specialists and General Practice is still under appeal in the

courts, leading to a delay in the final settlement. Disparity

correction is always controversial among specialists, and

there is no guarantee of future progress on this front,

although we are hoping and working, to ensure that this will

be an on-going process.

On the Pharmacare front, BC is on the verge of finally

accepting coverage for biologics for ankylosing spondylitis. At

present, only etanercept is covered by BC for psoriatic arthri-

tis. An appeal through the BCMA, has led to an agreement

with Pharmacare to also reduce the amount of paperwork

required for annual approvals for biologics, although bureau-

cratic processes have delayed institution of these reforms as

yet. We expect approval for at least one of the biologics for the

ankylosing spondylitis indication in the near future.

In Victoria, we are still in the process of getting used to liv-

ing with the new medical school. Rheumatology has been

involved in a very limited way so far, but we hope to have more

influence in teaching, and perhaps influencing students

towards a career in rheumatology in the near future. We have

two rheumatologists who are working part-time and one on

the verge of retirement, out of a complement of five. We have

an active CME program, with meetings of the Vancouver

Island rheumatogists bi-annually. We have been fortunate in

attracting several speakers of international stature, such as

Dan Furst and Vibeke Strand, to these meetings. Although

leisure is supposed to be part of the life-style of Victoria, the

local rheumatologists haven’t see much of it.

Notes from VictoriaBy Milton Baker, MD, FRCPC

Raynaud’s PhenomenonBy Peter Lee, MD, FRCPC

Not all clinically significant questions have been definitively answered by randomized double-blind placebo-controlled trials. The Hallway Consult by-line in the Journal of the Canadian Rheumatology Associationwill seek a consensus answer from rheumatologic experts for your difficult questions. Please forward questions for future issues to: Mandiw@sta.ca.

Management of Raynaud’s Phenomenon:Raynaud's phenomenon occurs in more than 90% of patients

with scleroderma and tends to be more severe in patients with

the limited form of disease and when compared to primary

and secondary Raynaud's phenomenon of other causes.

Scleroderma patients also have Raynaud's phenomenon that

is less responsive to vasodilator therapy because of the under-

lying vasculopathy involving the digital arteries with intimal

hyperplasia, vessel wall thickening and luminal narrowing.

The first step in the management of Raynaud's phenome-

non is to educate the patient on self-management with dress-

ing warmly in cold-temperature environments and avoiding

known precipitating factors such as handling cold objects and

emotional stress. Cessation of smoking is imperative but often

difficult to achieve.

Medical treatment of Raynaud's phenomenon is not always

necessary but indicated if despite the above measures, the

symptoms (pain, numbness or both) are severe enough to

result in impaired hand function. Treatment is obviously

required if the patient has developed ischemic lesions with

digital gangrene or ulceration. Initial treatment is usually with

an oral vasodilator. A long-acting formulation of nifedipine is

most frequently prescribed. However, use of this medication is

often limited by the occurrence of dizziness and headaches

even with lower doses. An appropriate starting dose would be

30 mg OD. Amlodipine and felodipine tend to be associated

with fewer hypotensive-type side effects. Losartan, an

angiotensin II receptor antagonist, has been shown to be more

effective than placebo and as effective as nifedipine, in a dose

of 50 mg OD and may be a useful alternative.

Topical nitroglycerin is sometimes useful in the treatment of

Raynaud's phenomenon. I have usually added this to the treat-

ment regimen when an oral vasodilator alone has not been

sufficiently effective. Hypotension is again the limiting factor

but can be minimized by administering the topical and oral

therapies 12 hours apart rather than together. In the case of a

digital ulcer, it is not necessary to apply the nitroglycerin

directly to the involved finger which tends to be messy and

can result in local skin irritation. Using a nitroglycerin patch

(anywhere on the body) is more convenient.

While widely prescribed in the treatment of more severe

Raynaud's phenomenon, the efficacy of oral vasodilators in

practice is quite limited and often inadequate especially if

ulceration or gangrenous changes have developed. In this

situation, more aggressive therapy is indicated but unfortu-

nately the choice of treatment with efficacy that has been

proven by randomized clinical trials is limited.

With severe Raynaud's phenomenon, complicated by

ischemic lesions, the use of prostaglandin analogues have

been shown to be effective, resulting in a reduction in fre-

quency and severity of attacks as well as improvement of dig-

ital ischemic lesions. Both alprostadil and iloprost appear to

have similar efficacy but the latter (which can be administered

through a peripheral rather than central venous line) is not

Case History: A 37-year-old male presents with a 10-year history of systemic sclerosis with limitedskin involvement and is seeking advice regarding management of his Raynaud's phenomenon. HisRaynaud's phenomenon is classic with tricolor changes of his fingers following cold exposure oremotional stress. On examination he has skin thickening that is limited to his fingers and back of hishands. Nailfold microscopy revealed the presence of capillary dilatation and ischemic areas withvessel drop-out. He was not able to tolerate previous treatment with nifedipine and amlodipinebecause of headaches. Marked improvement of his Raynaud's phenomenon occurred after anotherphysician treated him with a phosphodiesterase Type-5 inhibitor because of erectile dysfunction. Heis now able to wash dishes in cold water without colour change or discomfort of his hands.

22 CRAJ 2007 • Volume 17, Number 4

HALLWAY CONSULT

23

available in North America. Alprostadil is usually administered by

continuous intravenous (IV) infusion for a 72-hour period and in

the absence of cardiac manifestations is well tolerated.

Treatment is more effective if administered early before irre-

versible gangrene has developed or the ischemic ulcer has

become large (more than 5 mm in diameter).

The use of prostaglandin analogues is limited by the need

for continuous or repeated IV infusion and with alprostadil a

central venous line is necessary. Oral forms of prostaglandin

analogues have not been found to be effective. However, two

placebo-controlled clinical trials have shown bosentan (an

endothelin-1 receptor antagonist) to be effective in reducing

the frequency of recurring ischemic digital ulcers in patients

with scleroderma. However, the treatment did not increase the

rate of healing of the existing ulcers. The cost of bosentan is

extremely high and severely restricts its application in the

treatment of severe Raynaud's phenomenon.

An alternative treatment for severe Raynaud's phenomenon

is with phosphodiesterase Type-5 inhibitors. Efficacy has been

indicated in a number of case reports and in a small study

sildenafil 50 mg bid was found to be more effective than place-

bo in reducing the frequency and duration of attacks as well as

improving capillary flow and digital ulcers. As with bosentan,

there are no studies to indicate long-term efficacy and safety

with this treatment. Again expense is a limiting factor.

Obtaining either bosentan or sildenafil through provincial

health benefit plans is difficult if not impossible, primarily

because of the expense and the fact that Raynaud's phenome-

non is (not yet) an approved indication for these treatments.

In cases of severe scleroderma-related Raynaud's phenome-

non that have not responded to conventional therapy, alterna-

tive treatments to consider include oral anticoagulation with

warfarin and digital sympathectomy. I have personally

observed patients who have experienced a marked reduction

in the frequency of ischemic ulcers following oral anticoagula-

tion. Surgical cervical or lumbar sympathectomy is not an

effective long-term treatment and has long been abandoned

in the management of severe Raynaud's phenomenon.

However, chemical sympathectomy (cervical or lumbar) with

injections of local anesthetic may be effective in reversing local

vasospasm. Surgical digital sympathectomy has more recently

been advocated and claimed to be effective in anecdotal

reports. These treatments are unproven and their efficacy need

to be confirmed by randomized clinical trials but such studies

are seldom feasible because of the relative rarity of the disease.

Severe Raynaud’s phenomenon in patients with scleroderma

can be due to proximal macro-vascular occlusion and vascular

reconstruction in this situation may be helpful.

While there have been new and more effective therapies

available for the treatment of severe Raynaud's phenomenon

associated with scleroderma, the overall management of this

problem remains limited and frustrating.

PAGE HEADER

23CRAJ 2007 • Volume 17, Number 4

Sponsored by an unrestricted educational grant from Pfizer Canada.

Dr. Peter Lee is Director of the Scleroderma Clinic at the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, a

consultant rheumatologist at Mt. Sinai Hospital and Professor of Medicine at the University of Toronto, in Toronto, Ontario.

Editor’s Note: Compounded preparations of sildenifil or nifedipine have had some anecdotal success in treating mild Raynaud’s.

These topical preparations have not been subject to any reported clinical trails but should be further investigated.

The 2007 ACR Meeting in Boston

CRAJ 2007 • Volume 17, Number 424

Medical Publications: Where Do Rheumatologists Look fortheir Educational Information? By Glen Thomson, MD, FRCPC

24

JOINT COUNT

Strongly Strongly Responseagree Agree Disagree disagree Count

1. I get valuable and clinically-relevant information every month from:

Original research papers in peer-reviewed scientific journals 50% (67) 41.8% (56) 8.2% (11) 0 134

Review articles inscientific publications 49.6% (66) 45.1% (60) 5.3% (7) 0 133

Articles in monthly medicalpublications and

medical newspapers 12.1% (16) 46.2% (61) 37.1% (49) 4.5% (6) 132

Medical websites 21.4% (28) 42.7% (56) 28.2% (37) 7.6% (10) 131

answered question 134

skipped question 0

Source: Survey Monkey “Assessing Medical Publications,” December 2007

2. Every month, I read at least one complete:

Original paper in peer-reviewedscientific journal 63.9% (85) 33.1% (44) 2.3% (3) 0.8% (1) 133

Review article in peer-reviewed scientific publications 51.1% (67) 41.2% (54) 7.6% (10) 0 131

Article in monthly medical publicationsor medical newspapers 31.8% (42) 33.3% (44) 29.5% (39) 5.3% (7) 132

Article on a medical website 30.5% (40) 30.5% (40) 29.8% (39) 9.2% (12) 131

answered question 134

skipped question 0

Source: Survey Monkey “Assessing Medical Publications,” December 2007

The times may be changing but rheumatologists still

depend on the tried and true peer-reviewed medical

journals to be kept abreast of developments in medi-

cine. The vast majority of respondents read clinically-rele-

vant original scientific articles and review articles in these

publications on a monthly basis. Medical websites, newspa-

pers and magazines also provide clinically-relevant informa-

tion but only for about two thirds of the respondents.

Home is where most continuing medical education material

is read. Half the respondents will not take medical reading

material with them while traveling. Roughly one quarter of the

respondents would prefer electronic and not print versions of

most medical publications. This number may expand exponen-

tially as younger generations of physicians weaned on elec-

tronic textbooks and course material displace those accus-

tomed to the printed page. Forests may yet have a bright future.

CRAJ 2007 • Volume 17, Number 4 25

Strongly Strongly Responseagree Agree Disagree disagree Count

3. I do most of my medical reading:

At home 60.5% (78) 28.7% (37) 10.1% (13) 0.8% (1) 129

At work 22.8% (29) 42.5% (54) 28.3% (36) 6.3% (8) 127

When traveling 10.7% (13) 32.2% (39) 38.8% (47) 18.2% (22) 121

answered question 132

skipped question 2

Source: Survey Monkey “Assessing Medical Publications,” December 2007

4. I prefer printed (not electronic) versions of:

Peer-reviewed scientific journalswith original studies 45.9% (61) 27.1% (36) 23.3% (31) 5 133

Scientific journals whichpublish review papers 39.8% (53) 38.3% (51) 18.8% (25) 4 133

Textbooks 44.4% (59) 28.6% (38) 21.1% (28) 8 133

Medical newspapers andnews magazines 28.2% (37) 42.0% (55) 21.4% (28) 11 131

answered question 134

skipped question 0

Source: Survey Monkey “Assessing Medical Publications,” December 2007

Thank you to all those who participated and congratulations to Dr. Joyce Rauch of Montreal, Quebec who wonthe draw for a CRA mountain backpack!

Have you seen something amazing on the slopes?

Keep your camera close by for this year’s ThirdAnnual CRA Photo Contest from Mont Tremblant!Submit your best scenic and candid photos electronically by March 10th and you’ll have achance to win a CRA mountain backpack!

Please email entries to Mandi Watson:mandiw@sta.ca

Photo Contest2008

Publication of The Journal of the Canadian Rheumatology Association is madepossible through an unrestricted educational grant from Pfizer Canada.

The 2007 ACR Meeting in Boston

Zoom Zoom trying to make an extra buckselling the CRAJ at the hockey game.

The Divas of Canadian Rheumatology!

How come guys from “The Rock” always have two girls?

How come girls from Toronto always have three guys?

Hurry up and take the picture Glen so we can go back to partying!