Lessons from Master Clinicians: An Interview with Dr. Eric Matteson

TR: What skills, habits or experiences have you found most helpful in finding the right diagnosis in medical mystery cases that heretofore had been unsolved?

ELM: These mystery cases are what really interest and even delight us in rheumatology, and these cases may serve as professional and personal satisfiers in terms of intellectual stimulation and ability to make an impact. As I mentioned, there is no substitute for seeing lots of patients and keeping up on reading in the field. Only in this way can you learn the breadth and subtleties of disease and recognize unusual symptom complexes that can characterize these conditions.

Constantly going back to the patient to understand signs and symptoms, consulting the literature and your peers, and seeking advice from others are essential to cracking these cases, and sometimes even recognizing new disease entities. It is very thrilling to recognize a disease in a patient who has been sent to you after seeing many physicians and not receiving a diagnosis, but I must also say that I have often been just as thrilled when someone on our team comes up with the correct diagnosis. Sometimes you recognize the disease right from the history and exam at the first encounter but, more often, the diagnosis comes with carefully working through the disease features over some time.

TR: How do you approach the concept of uncertainty when entertaining a diagnosis for a patient?

ELM: If there is anything certain in medicine, it is uncertainty. Uncertainty is something that consciously, or sometimes unconsciously, should be taken into account by being as meticulous as possible in considering diagnostic possibilities and in developing treatment plans. It can have bad consequences in the form of over-diagnosis and overtreatment; in my experience; the latter is by far the most common and may lead to horrendous consequences. In our discipline of rheumatology, we become very humble by the variability of response to our treatments.

Uncertainty is inherent to the patient experience, too. For this reason, it is really important to focus on developing trust with patients and their families and to focus on shared decision making.

Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.