David - thanks. 1) with the Ctrl-Alt-Del approach there is no negotiation. Why try to make the patient a believer in an option they have already painted as bad. After all your the doc who prescribed the drug that caused her infection(s). The reason for her distrust in a drug doesnt matter. The goal is to get optimisim and as many choices on your side. 2) One thing I didnt put in this talk (that is in the lecture) is that we need new Flare management approaches. Steroids are, in the end, still chronically dangerous and if you need a steroid taper to make a DMARD work then you likely do not have a good DMARD choice. Tis always the season for a flare in RA, and its not limited to spring. Flare management may enable better control and durability of a DMARD - but right now you're using the same drug your fathers, fathers rheumatologist used to manage flares in 1960. I agree with the goal of Steroid use for flares, I just dont like that its the only option, especially in Difficult RA patients who by definition end up playing DMARD musical chairs! Thanks for the thoughts! JC