TR: How do you approach the concept of uncertainty when entertaining a diagnosis for a patient?
GH: In medicine in general, and especially in rheumatology, uncertainty is a familiar companion. One example of uncertainty is a patient with an ‘undifferentiated’ disease-phenotype. Those are interesting situations. If the duration of illness is brief and there has been no recognized pattern of end-organ damage, patients should know that
diseases often evolve and may not present as a fully developed picture. An illness may become more obvious and dictate a specific therapy or may even regress and resolve and be self-limiting. Patients need to know this and be reassured that you (and consultants, if necessary) will be available to follow this process and change course as needed.
In the meanwhile, you will be offering symptomatic therapy and monitoring them for any new subtle, as well as serious, developments. Patients often have more pressing questions: How did I get this? Will it go away? When can I return to work? How likely is it for my children to have this? Will these meds provide remission? Can it be fatal? I think we have to be transparent with our patients when the answers are not certain. They deserve nothing less.
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.
