As rheumatologists, we relish the thrill of diagnostic conundrums that accompany our immune-mediated multi-system and often undifferentiated disease processes. Many rheumatologic diagnoses are essentially diagnoses of exclusion. We’re accustomed to diagnosing iatrogenesis, infection and malignancy as often as we diagnose rheumatic disease. Complex clinical problem solving and critical reasoning are our forte, and to do them well requires expertise in many competencies of medicine that go far beyond an individual’s fund of knowledge, certainly including, but not limited to, teamwork, professionalism, feedback, history gathering, bedside manner, diagnostic testing and critical reasoning.
Explore This IssueJuly 2020
Although they differ in funds of knowledge, master educators model their clinical reasoning by a) thinking out loud and b) sticking to the basics.1 Teaching tactics used by master educators employ a blend of social cognitive theory, which underscores the role of modeling in learning, and Gestalt theory (described by Max Wertheimer in 1922), which underscores the valuable role of rules in learning. Simply stated, rules facilitate better learning and retention than memorization because rules provide a simpler description of a phenomenon, meaning less information must be learned.
Here, we describe 25 fundamental principles to help rheumatology trainees and rheumatologists alike navigate the clinical spectrum in our increasingly complex field.
1. The collective intelligence of a well-functioning team is higher than the intelligence of any individual. None of us knows everything. We operate as a team, with members at all levels of education and training, and we share the responsibility for teaching one another. Successful medical teams celebrate continuous learning, communicating well and listening to one another. Growing together as a team is one of the most satisfying, gratifying, enriching and rewarding aspects of medicine.
2. There is no shame in stupid questions, only in stupid decisions. Smart people sometimes ask stupid questions, and this should not be discouraged because it readily brings attention to critical learning opportunities for those tasked with the care of others. Judging questions as stupid poisons team culture and scares teammates from speaking up in moments when it may be crucial to do so.
As for stupid decisions, we have yet to observe a well-functioning team actually make one.
3. The more complex the patient, the more important it is for providers to talk directly to one another. In high-risk clinical scenarios that require multidisciplinary teams, our patients are always better off when we actually talk to each other. This has become harder to do as medicine becomes increasingly siloed. Reach out, and find the time and place to do this. You will never regret doing so.
4. “I don’t know” is a legitimate answer. Acknowledging the limitation of your knowledge is a valuable skill. Dealing with uncertainty is a common experience in the practice of rheumatology, and it can cultivate an enriching sense of humility. Don’t lose confidence in your uncertainty, for you are in good company: The most knowledgeable clinicians, after all, are often the first to acknowledge what they don’t know. When you are stuck on a case, don’t hesitate to discuss it with your peers or mentors. One of the least expensive tests you can order in a hospital is a consultation.
On Bedside Manners
5. Connection with the patient comes first. Patients are aware of the level of caring and commitment they receive. Two types of physicians exist: The physician who is in the patient’s room because they have to be there, and the physician who is in the patient’s room because they want to be there. The patient can tell the difference immediately.
Which type of physician are you? Every extra minute you spend building trust with a patient is worthwhile. A well-developed patient-physician relationship will serve both parties well in navigating clinical challenges that may occur in the course of continuing care.
On History Gathering
6. A properly formatted history of present illness (HPI) is your most valuable diagnostic tool. The patient history remains, among all diagnostic methods and resources employed by clinicians to this day, “the most powerful and sensitive and most versatile instrument available to the physician.”2
Although a thorough history is important to elicit the facts, how one strings the facts together is a critical piece of the puzzle. Understanding which aspects of the HPI are relevant to the disease history is not a simple task, but a skill—one requiring knowledge and clinical experience.3 The knowledgeable evaluator can predict an accurate diagnosis in up to 85% of medical cases by skillfully combining an analysis of the presenting patient concern and properly sequencing all relevant prior aspects of the patient history.4-6
7. Trust, but verify. Many labs, imaging studies and biopsies are misinterpreted or misreported and then misleadingly propagated through the records. Always review the original data, and make an independent assessment—your reputation and the patient’s health depend on it.
On (Immuno) Laboratory Testing
8. Just because you can measure it doesn’t make it meaningful. Don’t hesitate to order tests that can possibly help the patient, as long as they have some useful positive or negative predictive value. And don’t order tests if the results can’t be interpreted.
9. Treat the patient, not the numbers. Immunology labs, although helpful, are seldom conclusive.
10. Did we cause this? Iatrogenesis is a common cause of disease, with a very simple treatment—stop the drug. Always consider it first, and you’ll be less likely to overlook it.
11. Steroids are not a diagnosis. Too often, rheumatologists are referred patients without a diagnosis who have been empirically started on steroids. Steroids can mask features of any inflammatory state. When seeking a diagnosis, don’t hesitate to taper steroids to unmask the underlying disease process.
12. You can have fleas and lice at the same time. Many clinicians emphasize Occam’s razor, which suggests the simplest explanation is the most likely, but don’t forget Hickam’s dictum—a patient can have as many diseases as they darn well please. Consider whether two diseases may be occurring at the same time. This is of particular consequence when tackling comorbidities with opposing treatments, as is often the case in rheumatology.
You’ll likely be asked: “Is it rheumatism or infection?” Remember the answer is often, “yes, it’s both rheumatism and infection.”
13. When overwhelmed by clinical abnormalities, find the pivot point. The pivot point is a specific clinical abnormality that must be accounted for in the diagnosis and thus—especially when combined with salient features—can frame and guide the differential diagnosis.
14. Never lose your sense of curiosity when evaluating a patient. Overconfidence, anchoring and premature closure are the triad of morbidity in rheumatology. Once a diagnosis is made, don’t stop thinking.
Patients often benefit from an uncertain physician, particularly one who is aware of their uncertainties. Sir William Osler once said, “Medicine is a science of uncertainty and an art of probability.”
Always review the original data, & make an independent assessment—your reputation & the patient’s health depend on it.
Beware of complacency, never overlook something that seems simple, and always reserve the right to change your mind. We are all vulnerable to biases, so slow down, take mental time-outs, and rheuminate: What else could this be? Which data fit, and which don’t? What would I hate to miss?
Become an expert in the mimics that can masquerade as rheumatic disease; you will encounter them at least as often as the rheumatic disease everyone else may be considering. Diseases can evolve, and so should your diagnosis and management. And don’t forget the zebra and unicorn diagnoses. Even though you may rarely see them, at some point they will see you.
15. Sometimes the best thing to do is observe. Patients will come to you at different points in their disease. Remember that most rheumatic diseases develop along a continuum: genetic risk → environmental risk factors → systemic autoimmunity → symptoms → undifferentiated syndrome → differentiated syndrome.
Patients won’t necessarily pass through every stage, and stages can spontaneously remit, develop quiescent disease activity or become non-progressing.
In cases of serological autoimmunity or undifferentiated disease, most will either spontaneously resolve or eventually declare themselves.
16. The most crucial step toward healing is having the right diagnosis. We are often asked early in an investigation, what will be the treatment? The most accurate answer comes with having the most accurate diagnosis. Unless the patient may die or endure major morbidity before a diagnosis can be made, pursue as definitive a diagnosis as the clinical scenario requires.
17. Medications only work in patients who take them. Patients fear medications. Studies have consistently shown that approximately one-third of prescriptions go unfilled, and of the ones that are filled, only half are taken correctly.7 Assess adherence in every patient at every visit (without judgment). If the patient is non-adherent, recall that doctor is derived from the Latin docēre, which means to teach: Encourage and empower your patients with knowledge so they can make better informed decisions for themselves.
18. If treatment is not working as expected, challenge the diagnosis. Treatment failure can be a crucial diagnostic clue. Never presume the patient is a slow responder or the disease is refractory without first rechecking the history and physical exam, re-reviewing the data and revisiting the differential diagnosis.
19. Always do a formal consultation. Avoid declining a consult request (misdirected though it may seem) or providing curbside consults (busy though you may be). The referring provider will convey the facts of the case as they appear to them, which may be chock-full of biases. Always make an independent assessment before providing recommendations that will affect the patient.
20. They don’t just need us for our knowledge; they need us for our wisdom. A revered colleague and American College of Physicians Master would often joke that “rheumatologists are glorified internists.” Although the expectation for a consultant may be to answer the consult question, a great consultant will also answer the questions the referring provider didn’t know to ask, but should have.
21. Write your notes imagining you are at a morbidity and mortality (M&M) lecture and your note flashes on the screen. For anyone who’s sat in a departmental M&M and seen their note on the screen, it was likely a moment of great pride or great anguish. Well-done M&M lectures that include actual clinic notes have tremendous potential for shifting institutional culture toward clinical excellence. When writing your assessment and recommendations, be self-aware of biases and honest about the limitations of your knowledge; document them accordingly.
22. Feedback is important regardless of the line of work, but even more so in ours—in which patients’ lives and liability are at stake. Feedback should be a two-way street, and we all need it if the goal is to improve. In medicine, where we must work hard to achieve our goals, we need to quell arrogance and remain humble. Some of our most important lessons come from experiences that are uncomfortable, and sometimes painful, but they should always occur in a supportive setting where we can feel safe to be vulnerable and readily learn from our mistakes and those of others.
We can learn from Groucho Marx, who once said, “Learn from the mistakes of others. You can never live long enough to make them all yourself.”
23. Know your patient. Obtain these four data points on every patient: where they’re from, who they live with, what they like to do and how their illness impacts their life. These are useful memory anchors, and they add meaning to the work we do.
Burnout in medicine is real, and it may not be the long hours that cause burnout
so much as the economic pressures
driving productivity and increased time spent interfacing with computers that are dehumanizing medicine. We need to preserve the humanity in medicine, not only for our patients, but also for ourselves. The reward of treating rheumatoid arthritis is trivial compared to that of treating “a 30-year-old concert pianist and father of newborn twins who has rheumatoid arthritis.”
24. Be kind to yourself. Our failures in medicine can have grave consequences for others; to do what we do, we need to have a plan for these setbacks, because they will happen. If we can’t take care of ourselves and preserve ourselves, we won’t be able to help anyone ever again. This is why it is critical the healthcare environment be one of support and safety.
On Clinical Teaching
25. To be a good clinical educator, follow three rules:
- Be kind;
- Think aloud; and
- Stick to the basics.
This was a lesson from a master clinical educator who humbly simplified his masterful teaching approach to just these three rules: Treat your colleagues with kindness and respect to cultivate a culture conducive to optimal learning. Thinking aloud demystifies the process of clinical reasoning by modeling it for learners. And sticking to the basics, such as the rules described herein, reinforces foundational skills in the practice of medicine and rheumatology.
Wrapping It Up
The biomedical knowledge of rheumatic diseases and treatments grows every year, so it can be challenging to standardize the most important content in rheumatology curricula. The most consistently crucial elements of the practice of rheumatology that clinical educators can bestow upon rheumatology fellows are skills, rather than biomedical knowledge. Skills are likely to withstand the test of time and remain the bedrock of our field.
Laura Upton is a graduating medical student from Georgetown University School of Medicine.
Adam Kilian, MD (@KilianMD), is an assistant professor of medicine, rheumatologist and rheumatology curriculum co-leader for the Rheumatology Fellowship Program at the George Washington University School of Medicine and Health Sciences, Washington, D.C.
- Houchens N, Harrod M, Fowler KE, et al. How exemplary inpatient teaching physicians foster clinical reasoning. Am J Med. 2017Sep;130(9);1113.e1–1113.e8.
- Faustinella F, Jacobs RJ. The decline of clinical skills: A challenge for medical schools. Int J Med Educ. 2018 Jul 13;9:195–197.
- Kilian A, Upton LA, Sheagren JN. Reorganizing the history of present illness (HPI) to improve verbal case presenting and clinical diagnostic reasoning skills of medical students: The all-inclusive history of present illness (AIHPI). Submitted to J Med Educ Curric Dev. 2020 Jun 10. https://doi.org/10.1177/2382120520928996.
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- Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: A systematic review. Ann Intern Med. 2012 Dec;157(11):785–795.