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.
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.