Learn to Navigate the Seas of Uncertainty in Rheumatology Training

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Rheumatology is a field rife with uncertainty. With regard to both diagnosis and treatment, we live in a world of rare diseases that are difficult to study. As a result, we are often left without an answer to our diagnostic dilemmas and without clarity when deciding the best treatment options for our patients. For rheumatologists to cope with, and thrive during, times of uncertainty requires that we recognize and prepare for this unique challenge of our field.

Navigating the seas of incertitude can be a formidable task for a fellow. I remember the astounding feeling my first month on the inpatient consult service as I experienced the steep learning curve of understanding complex rheumatic diseases. At the start of training, we don’t yet have the illness scripts needed to make accurate diagnoses. Creating accurate illness scripts requires pattern recognition, yet our diseases don’t always follow the rules or fit into neat boxes. Learning to understand such enigmatic disease processes can, at times, feel like an immense task.

Dealing with uncertainty as a fellow can also be emotionally burdensome. During internal medicine training, a sense of satisfaction comes from the concrete inputs and outputs in our decision making when caring for patients with such conditions as congestive heart failure and sepsis. In contrast, a new rheuma­tologist can sometimes feel like ambiguity is the norm.

As internists, we strive to find definitive answers, and immersion in a field that does not always offer them results in an uneasiness not previously experienced in our medical training. But this also offers a unique challenge and is part of the fun and draw of rheumatology as a field. Many internists who choose rheuma­tology are captivated by the detective work involved.¹ Yet there is a crucial, humbling lesson to be learned in not always solving the mystery. Understanding this is an important step for a rheuma­tology fellow.

Although it is frustrating not to know the answers ourselves, it is even more difficult at times to not have answers for our patients. These are challenging conversations to navigate. We learn the art of both simultaneously exuding confidence while also endorsing flexibility. We learn how to recommend medications without certainty of their benefit for that particular patient.

We approach these quandaries by practicing shared decision making and by explaining all the risks and benefits of our recommendations. But the realities of uncertainty are part of our relationships with patients. Embracing this aspect of our physician-patient relationships presents yet another monumental endeavor for trainees.