What Is the Essence of Being a Rheumatologist?

I am often asked by medical students, resident physicians and—especially—patients, what is rheumatology? When students ask me why I chose to be a rheumatologist, I answer that I have never been in love with pathologies, such as rheumatoid arthritis, spondyloarthritis, gout, osteoporosis, systemic lupus erythematosus or vasculitis. In fact, I chose rheumatology because I love internal medicine. Thinking about it, I started to question whether adult rheumatology is another face of internal medicine—if it’s something more than just a subspecialty.

In conversations with other rheumatologists, I notice that we find it difficult to express what our subspecialty actually means. Many people reduce the definition of rheumatology to a description of our routines, but what we do does not define us. For example, saying rheumatologists take care of autoimmune diseases is not essentially our role; after all, we deal with a wide range of pathologies that don’t necessarily include autoimmunity (e.g., osteoporosis, osteoarthritis, gout). Likewise, numerous other subspecialties deal with autoimmune diseases that rheumatologists don’t manage (e.g., Hashimoto’s thyroiditis, multiple sclerosis, pemphigus).

Alternatively, some may suggest we deal with diseases that afflict the musculoskeletal system. Once again, this does not define us; many collagen vascular diseases, as well as IgG4-related disease, don’t necessarily have musculoskeletal manifestations.

In search of the answer to what is, in fact, the essence of rheumatology, I went back to the etymology of the word rheumatism. In the Encyclopedia Britannica, rheumatism is described as “any of several disorders that have in common inflammation of the connective tissues, especially the muscles, joints, and associated structures.”¹ In fact, rheuma originates from ancient Greek and means “to flow,” a direct reference to the theory of the four fluids (i.e., humors) applied to medicine by Hippocrates, Galen and others. This theory suggests that diseases result from an imbalance of humors.

If we consider that the theory of the four fluids (i.e., blood, phlegm, yellow bile, black bile) represented human physiology and that rheuma would imply imbalance among these fluids—mainly, but not restricted to, phlegm—I infer the rheumatologist is the “specialist in the whole body.” Knowing that connective tissue is the most abundant tissue type in our body and that its main function is to support and connect body parts, we gain insight into the definition of rheumatism given by the Encyclopedia Britannica and why we are considered experts in “connective tissue inflammation.” Yet I still think it’s an incomplete definition because it leaves out the three other classically defined basic tissue groups (i.e., muscles, epithelium and nerves), all of which are often affected by rheumatic disease.

I really don’t know what the essence of being a rheumatologist is, but as St. Augustine wrote, “Let us be more content to find the truth, not understanding it, than to understand without finding it.”² Therefore, I believe the essence of being a rheumatologist lies in the art of unraveling mysteries. This is why we are called in when other specialists cannot unravel a patient’s problem.

Because there is nothing more enigmatic than ourselves, I would say, without a doubt, that we rheumatologists are specialists in human beings.

Carlos Antonio Moura, MD, is a rheumatologist and staff of the internal medicine residency program at Hospital Santo Antônio and Hospital Geral Roberto Santos, in Salvador, Bahia, Brazil. He also teaches at Salvador University and Escola Bahiana de Medicina e Saúde Pública. (Twitter and Instagram: @Rheumaspeak)

Carlos Geraldo Moura, PhD, is a rheumatologist and chief of the internal medicine residency program at Hospital Santo Antônio in Salvador, Bahia, Brazil, and teaches at Escola Bahiana de Medicina e Saúde Pública.

References

1. Rheumatism. Encyclopedia Britannica. https://www.britannica.com.
2. Agostinho [St. Augustine]. Confissões [Confessions]. Brazil: Ciranda Cultural, 2019.