What attracts physicians to a career in rheumatology? Traditionally, the foundation of clinical training at both the medical student and house staff level is based on inpatient services. There are many reasons for this, predominantly revolving around access to patients available for teaching. The result: Trainees are predominantly exposed to a group of conditions that either provide an answer or run their course in a period of two weeks. One becomes an expert in the diagnosis and immediate management of conditions associated with hypoxia, sepsis, hypotension, etc. These dysfunctions are also frequently remedied or diagnosed over the short term and provide immediate positive feedback to physicians in training.
Chronic disorders, such as diabetes mellitus, chronic obstructive pulmonary disease and rheumatoid arthritis, are best understood when followed over a prolonged period of time in the ambulatory arena, a site that has always been difficult to incorporate into educational programs at all levels. The formation of long-term relationships with a patient and the opportunity to observe both spontaneous fluctuations in a disease and the delayed response to intervention is seldom experienced by trainees. This is unfortunate because so much of the unique challenge and joy in medicine occurs in caring for patients with these conditions.
Involvement in providing long-term care teaches one not only about the disease, but also about the person with the disease. How do they function despite it all? How do they deal with their multiple challenges? Caring for such patients will have periods of adversity and frustration, but also times of celebration. Misdirections and blind alleys will often occur. Early in my career I became aware that, often, the most grateful patients were not those who were doing well by the usual objective criteria, but those who appreciated my continued effort and concern. One realizes that style points are often awarded, especially in the field of rheumatology.
A Single Patient
Sometimes an experience with an individual patient may alter your career decisions. In the era in which I was a house officer, interns—particularly in a city hospital—were responsible for starting intravenous (IV) drips and drawing blood. This duty was not without its benefits, although they were not always appreciated at the time. Not only did this encourage more selectivity about what labs to obtain, but it also strengthened a trusting patient relationship, often more dependent on phlebotomy skills and effective personal interaction than a knowledge of medicine. It provided an interval of time in which you were totally committed to your patient.
One of my patients at that time was a lovely, resourceful woman in her 70s. She had longstanding, crippling rheumatoid arthritis and had been admitted for leg ulcers. My daily rounds were not just a perfunctory glance at the wounds, but a longer stay in which I dressed the wounds and attended to drawing blood and maintaining IV fluid access. During these visits we had discussions in which she taught me what it was like to live with a chronic disabling disease.
Similar to most young physicians in training at that time, I had been drawn to the excitement and immediate rewards associated with acute, potentially reversible illnesses. This experience provided me with insights into the challenges of a chronic disease that would not have been available without this period of time spent with this patient. I remember her and what she taught me to this day—not in small part because she spent her days knitting a sweater for my newborn daughter.
Time spent just talking to patients fosters the development of empathy and can expand your horizons in multiple ways that may not be apparent to you at the time.
When I made my decision to become a rheumatologist in the mid-1960s, only three areas had internal medicine subspecialty boards: cardiology, pulmonology and gastroenterology. I was never convinced those subspecialties with boards did any better with teaching, research or patient care than those without boards. Medical residency in that era focused on the training of general internists and lasted for three years after internship. Many who chose to subspecialize in a discipline without subspecialty boards would spend 6–12 months of their final year of residency in the chosen discipline and enter practice as an internist with a particular interest in a given field, such as rheumatology, endocrinology or hematology. Physicians took a formal fellowship—as I did—only because of a desire to work in an academic medical center. My two years as a fellow were predominantly laboratory based, which was the custom at that time.
I was drawn to rheumatology because I was attracted by the challenge of the many systemic and essentially untreatable aspects of rheumatological conditions and encouraged by the relationships I had formed with such patients during my internship and residency. I was particularly intrigued by conditions that did not have an easy cure and was convinced patients who could not be cured needed a physician as much as, or more than, those who could be easily cured.
The dependence on history and physical exam, plus the ability to use these readily available modalities to make decisions and separate the walking wounded from the worried well also strongly affected my decision. In addition, I was convinced that significant advances would be made in the treatment of these disorders during my career.
During my residency I also decided I wanted to function as a clinician and teacher in an academic medical center. To be effective in this role, I was of the opinion that it was essential to be challenged on a regular basis by caring for patients with whom I had a personal relationship. Although I loved the immediate gratification of intervening in the conditions of patients with acute illnesses, I realized that, as an attending on such a service, the house staff would have all of the fun and my role would be to pontificate on Monday morning about what had happened the night before. I felt a predominantly ambulatory practice focused on difficult rheumatologic diseases would allow me to savor the joys of being a physician while also being actively involved in clinical teaching.
Choosing rheumatology was a good decision, and in many areas, my vision became a reality. The development of effective orthopedic interventions in the 1970s, the addition of methotrexate as the cornerstone of medical therapy in the 1980s and the arrival of several biological agents starting in the 1990s have tremendously affected the course of many conditions seen in the practice of rheumatology. Waiting rooms in the 1960s were filled with patients using assistive devices, wheelchairs and—not infrequently—stretchers, all of which have become a thing of the past.
Happiest of All Specialties
A recent poll revealed that rheumatology is the happiest of all specialties.1 Why would this be? It certainly is not related to compensation. In fact, in 1992, M.J. Prashker documented by economic analysis that choosing to train in rheumatology was a poor financial decision with a lifetime net loss when including time spent in fellowship in the equation.2
The appealing aspects of rheumatology are multiple: the opportunity to experience long-term relationships with patients, the challenge of dealing with a set of conditions with an unknown etiology, the use of history and physical examination as the cornerstone of practice, the experience of dealing with variability and uncertainty, and a way of life that is demanding yet compatible with a fulfilling personal and family life.
Rheumatologists tend to be satisfied in the role of a guide or counselor, rather than as a heroic interventionist. Few immediate successes or cures occur in the practice of rheumatology, and immediate gratification for either the patient or the physician is rarely seen.
With the exception of a joint aspiration and injection or the initial use of prednisone in polymyalgia rheumatica, the patient will rarely experience an immediate benefit following the first visit and, thus, attribute it to the physician’s skill. Our most effective interventions have a delayed onset of action.
The goal of the initial visit should always focus on the creation of a trusting relationship, education regarding the condition affecting the patient and plans for dealing with it. This concept of immediate vs. delayed success became obvious to me in my first few months of practice. Mr. R presented with the onset, one month previously, of severe polyarticular rheumatoid arthritis, which began while he was vacationing in Florida. He was a pleasant, late middle-aged man, somewhat unpolished in manner, who had created a successful business manufacturing furniture. He described his encounter with a physician in Florida who aspirated and injected his knee with corticosteroids as follows: “I thought I had died and gone to heaven! Terrific! The next day I had a sofa delivered to his home.”
At this time, I had just finished my fellowship; we had bought our first house and had three children. My wife and I slept on a mattress on the floor and the only sofa in the house was a futon. I immediately called home.
“Forget any thought of buying furniture now. If this patient remits on gold [the cornerstone of therapy at that time], we could furnish the whole house! Let’s see what happens.”
Gradually, over the next few months, he went into a clinical remission, and although he remained a loyal and grateful patient for several decades, my reward that first year was a bottle of Scotch at Christmas.
An axiom in our practice is that the appearance of a box of homemade cookies in the workroom, donated by a grateful patient, is virtually pathognomonic of the recent initiation of prednisone for polymyalgia rheumatica.
The practice of rheumatology encompasses all of the fundamental skills and principles inherent in internal medicine in addition to an understanding of the essentials of orthopedics. However, several features are unique to the conditions most commonly managed, the systemic rheumatic diseases. Most of these disorders are of unknown etiology and follow a variable course over time. Inflammation is a potentially reversible process, sometimes with the possibility of a spontaneous remission.
Over the years, it has been my observation that at any follow-up visit, unrelated to the intervention employed, the presentation of one-third of patients with rheumatoid arthritis or other rheumatic condition will be improved by objective criteria, one-third will be worse, and one-third will be the same. Given the chronic optimism of most patients, over one-half will report improvement, one-quarter will feel worse and one-quarter will state they are the same. It is not unique to have a patient who, over the years, always tells you they are better and, rarely, those who invariably state they are worse.
Therefore, to be effective as a rheumatologist you must achieve better than a 50% success rate.
‘I was drawn to rheumatology because I was attracted by the challenge of the many systemic and essentially untreatable aspects of rheumatological conditions.’ — Ronald J. Anderson, MD
Rheumatology vs. Oncology
It’s useful to compare how the general approach to management differs between oncology and rheumatology. Both require a comprehensive program of care involving multiple medical and surgical disciplines aimed at a difficult disease. With cancer the natural course is to get worse and spontaneous remissions don’t occur. Reappearance of the disease is ominous and is dealt with aggressively. Therapy is aimed at the eradication of the process. Cures sometimes occur and are often the goal of treatment.
In contrast, most rheumatic disorders are potentially reversible and have a natural course marked by variability. Spontaneous periods of remission or improvement are often seen. This pattern of disease activity is most frequently observed in patients with systemic lupus and variants of spondylitis. Not all manifestations of these diseases do permanent harm, and mere observation is often a reasonable option. Therapeutic interventions are aimed at suppression of the process. Curative therapy seldom exists.
In contradistinction to cancer, in which the diagnosis is almost invariably certain and characteristically based on a definitive histological finding, many rheumatic diagnoses are essentially exclusion diagnoses. Laboratory studies, although helpful, are seldom conclusive. The exceptions are crystals in the joint fluid, positive blood or synovial cultures, and a few syndromes with a characteristic vascular or renal histology, such as giant cell arteritis.
You should become an expert in the exclusions that can masquerade as a systemic rheumatic disease. They often are more likely to respond to a specific intervention, and making the correct diagnosis is usually dependent on one’s skills as a competent general internist. Examples from my experience that still provoke warm memories are osteomalacia, endocrinopathies of several types and covert infections. Although these are relatively rare conditions, the benefit of the diagnosis is huge, and the rewards often dramatic. Be on the lookout. Sometimes, you must kiss a lot of frogs before you find a prince. Relish the thrill that occurs when one appears.
Making a Diagnosis
The most common conditions, rheumatoid arthritis and systemic lupus, have only classification criteria and not diagnostic criteria. In a sense, classification criteria are used in writing papers, but not necessarily for making decisions for a specific patient. Often, despite a thorough and complete evaluation, you can’t make a definite diagnosis. In a greater sense, this is a blessing, because once you make a diagnosis, the tendency is to stop thinking. Patients will often benefit from an uncertain physician, particularly one who is aware of their uncertainties.
The Minestrone Soup Talk
Patients will sometimes ask, “How do you know I have lupus?” One response is the “minestrone soup talk,” the essence of which is:
“The diagnosis of lupus is similar to the diagnosis of minestrone soup. No single ingredient or combination of ingredients will confirm or exclude the diagnosis of either lupus or minestrone soup. Each has many variations. However, no matter how minestrone presents, it is never confused with clam chowder.”
When you label a patient with a specific diagnosis, it should have both therapeutic and prognostic implications. Many syndromes encountered in the practice of rheumatology remain “unclassifiable” even over a prolonged period of follow-up. Over two decades ago, I prospectively reviewed the records of 200 consecutive new patients seen in my practice.3
Eighteen (9%) patients in this group were unclassifiable at the time of initial presentation despite objective evidence of a disorder. All patients had at least one physical finding characteristic of a systemic rheumatic disease (synovitis in 16 and rash in two patients), but otherwise did not meet criteria for a specific diagnosis by accepted standards. They were categorized as having an “unclassifiable systemic rheumatic disease.” All but one patient, who was lost to follow-up at five years, were followed for nine years, at which time the data were analyzed. A specific diagnosis evolved in only two patients (psoriatic arthritis and rheumatoid arthritis with interstitial lung disease). Four patients underwent a complete spontaneous remission. The remaining 11 patients did not evolve into a specific diagnosis by accepted classification criteria despite the prolonged period of follow-up. Nine patients improved with treatment, one deteriorated, and another died with interstitial lung disease.
Such patients are seldom reported in the literature, yet they were among the five most common diagnoses seen on both initial and follow-up visits in my practice.
The greatest body of medical knowledge is based on conditions that don’t get better. Many conditions we only observe and don’t understand. Dealing with uncertainty is a common experience in the practice of medicine and particularly in rheumatology. It often creates a sense of humility, which in itself can be enriching. Although, to the best of your knowledge, you may never have seen a case of the condition you are confronted with, it is probable that, sometime in the past, the condition has seen you.
Never be afraid to tell a patient you don’t know something. It may be a challenge to then convince them they are seeing the right doctor, but it can be done and is the most honest course to follow.
Avoid the Onset of Complacency
After a spending many years in the practice of medicine, particularly in rheumatology, one should become alert to the threat of the insidious onset of complacency and a tendency to become less critical of yourself and your skills. The longer you practice, the more you tend to accumulate patients who like you, laugh at your jokes, tolerate your inadequacies and reinforce your every action. Those who are dissatisfied with the care they receive leave early for greener pastures. Eventually, you become part of a large, happy family populated with grateful patients and strains of Kumbaya playing in the background.
I believe two factors have been critical in my career to help ward off this situation:
1. Patients: They are always a challenge, restorative in so many ways and bring something new to the table with each visit. They provide perspective. When you care for patients, you learn you’re never as bad as you fear you are when things go wrong or as great as you aspire to be when things go well. Sometimes you’re the windshield, and sometimes you’re the bug.
2. Involvement in the education of young physicians and relationships with colleagues: During my residency years I became convinced my goal was to become a clinician and teacher in an academic medical center, although such positions did not exist at that time. I was advised by several colleagues that my attraction to clinical teaching was essentially a result of the collegial relationships I enjoyed with my fellow house officers. I was told that as I became more senior and no longer shared experiences and attitudes that were age specific, I would outgrow my enthusiasm for this activity. This did not happen.
I believe the fun and collegiality of a career as a rheumatologist persist and are based on common goals, experiences and challenges related to patient care.
Ronald J. Anderson, MD, currently in his sixth decade of clinical teaching and patient care, has spent the majority of his career at Brigham & Women’s Hospital and Harvard Medical School. He was named a Master of the ACR in 2001 and in 2012 was honored by the ACR as the initial recipient of the Distinguished Training Program Director Award.
References
- O’Dell JR. The happiest specialty: Rheumatologists are #1. The Rheumatologist. 2012 Jul;6(7).
- Prashker MJ, Meenan RF. Subspecialty training: Is it financially worthwhile? Ann Intern Med. 1991 Nov 1;115(9):715–719.
- Anderson RJ. Nine year follow up on patients presenting with unclassifiable systemic rheumatic disease (USRD) [abstract]. Arthritis Rheum. 2000 Sep;43(Suppl 9):S296–S297.
This article was adapted and reprinted from a chapter in Lessons Learned in the Care of Patients: A Rheumatologist’s Perspective, by Ronald J. Anderson, MD, with the expressed permission of the author.
