On Assessment
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.
