For Residents, Mystery Patients Often Require Rheumatologist Advice

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As a first-year internal medicine resident, I find myself consulting rheumatologists for just about every mystery patient in our hospital. Like many residents, I was initially intimidated by the complexity of this elusive field. At first glance, diagnosis and management seem completely inaccessible to a first-year resident. But several rheumatology consults later, I can confidently say that understanding the basics is certainly worth the time.

Diagnosis without Knowledge

In the era of cost-effective medicine, we are taught to be judicious when ordering labs and imaging. To do so, we must understand how each test will help us care for our patients.

When it comes to rheumatic disease, however, the average resident lacks such understanding. We send off a battery of immunologic tests with a vague idea of how these results will guide our management. How much do we really care about a positive anti-nuclear antibody (ANA)? How often do we track complement levels, and why are we doing it in the first place? We turn to rheumatologists to guide us every step of the way.

Many of us grow comfortable with this lack of understanding. After all, the expectation for a resident is not to know rheumatology, and there is plenty to learn just in the realm of bread-and-butter internal medicine. This comfort can prove problematic, however, when it interferes with our radar for rheumatic disease. As the first line of care for the hospital, we must know enough to consider these diseases in our differential diagnosis on admission. This is especially important because what we do in the first few hours of admission tends to lead to anchoring bias, which then steers the course of the patient’s hospitalization.

Symptoms may be vague, lab tests require careful interpretation and treatment can prove toxic. Those who have yet to be diagnosed with rheumatic disease may slip through the cracks without appropriate workups. Those with known rheumatic disease may be taken off important disease-modifying medications, leading to disease flares and unanticipated sequelae in the hospital.

Given the significant shortage of rheuma­tologists, particularly in rural America, internal medicine physicians often must start a workup without the input of a rheuma­tologist. It follows, then, that our training should prepare us to feel comfortable diagnosing these conditions.

What Exactly Is So Challenging?

First, there’s a steep learning curve. The field is incredibly dynamic, and guidelines often lag behind practice-altering research developments. In short, the clinical decision-support resource UpToDate is not sufficient for learning the day-to-day practice of rheumatology.