For Residents, Mystery Patients Often Require Rheumatologist Advice

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As a first-year internal medicine resident, I find myself consulting rheumatologists for just about every mystery patient in our hospital. Like many residents, I was initially intimidated by the complexity of this elusive field. At first glance, diagnosis and management seem completely inaccessible to a first-year resident. But several rheumatology consults later, I can confidently say that understanding the basics is certainly worth the time.

Diagnosis without Knowledge

In the era of cost-effective medicine, we are taught to be judicious when ordering labs and imaging. To do so, we must understand how each test will help us care for our patients.

When it comes to rheumatic disease, however, the average resident lacks such understanding. We send off a battery of immunologic tests with a vague idea of how these results will guide our management. How much do we really care about a positive anti-nuclear antibody (ANA)? How often do we track complement levels, and why are we doing it in the first place? We turn to rheumatologists to guide us every step of the way.

Many of us grow comfortable with this lack of understanding. After all, the expectation for a resident is not to know rheumatology, and there is plenty to learn just in the realm of bread-and-butter internal medicine. This comfort can prove problematic, however, when it interferes with our radar for rheumatic disease. As the first line of care for the hospital, we must know enough to consider these diseases in our differential diagnosis on admission. This is especially important because what we do in the first few hours of admission tends to lead to anchoring bias, which then steers the course of the patient’s hospitalization.

Symptoms may be vague, lab tests require careful interpretation and treatment can prove toxic. Those who have yet to be diagnosed with rheumatic disease may slip through the cracks without appropriate workups. Those with known rheumatic disease may be taken off important disease-modifying medications, leading to disease flares and unanticipated sequelae in the hospital.

Given the significant shortage of rheuma­tologists, particularly in rural America, internal medicine physicians often must start a workup without the input of a rheuma­tologist. It follows, then, that our training should prepare us to feel comfortable diagnosing these conditions.

What Exactly Is So Challenging?

First, there’s a steep learning curve. The field is incredibly dynamic, and guidelines often lag behind practice-altering research developments. In short, the clinical decision-support resource UpToDate is not sufficient for learning the day-to-day practice of rheumatology.

Second, rheumatic disease remains shrouded in mystery. As residents, we tend to feel comfortable when we know the pathophysiology behind the disease we treat. The science makes us feel safe that the benefit of medical intervention outweighs the harm. Rheumatology, however, requires us to remain open to the possibility that management may not be clean-cut, and that each patient requires an individualized approach. Residents in rheumatology must accept a degree of unknown to a greater extent than in other subspecialties.

Third, treatment requires careful consideration. Starting someone on long-term steroids, biologics or pain medications can be scary for many reasons—not only do the medications come with significant adverse effects, they also may come with a high price tag. Residents must consider what may be cost-prohibitive to the patient, and then appropriately adapt the treatment plan in conjunction with the rheumatologist.

Personal Growth & Patient Support

These challenges also demonstrate how rheumatology exemplifies the art of medicine. If only as an intellectual exercise, navigating these muddy waters helps us grow as physicians and advocates for our patients.

Supporting a patient through uncertainty, setting appropriate expectations for progress and presenting the risks and benefits of an intervention are all important skills when counseling patients in all disease states. We also must explain this information in a manner that makes the patient feel comfortable participating in their care and asking questions as they arise. In other words, rheumatology requires physicians to build a strong therapeutic alliance with their patients.

Gain Awareness Now

I’ve compiled a list of resources to help the average resident feel more comfortable diagnosing and treating rheumatic disease (see sidebar, left). With more awareness, we can learn to ask the right questions and reduce delay to diagnosis for these vulnerable patients.

Veena S. Katikineni, MD, is an internal medicine resident at Inova Fairfax Hospital, Falls Church, Va.