July 2
It is my first day of fellowship, and my first patient walks into clinic. Mr. H is 26 years old, but looks 17. He is alone. He has a history of knee swelling and recurrent effusions. Then he developed skin changes—itchy red and white flakes all over his scalp. He was sent to the rheumatology division by his knee surgeon for further evaluation. The diagnosis was clear. We spent most of the visit explaining the implications of psoriatic arthritis. We were going to start methotrexate. The side effects include infections.
I pause.
I think about the past five months confronting COVID-19. It is a strange time. Restaurants are closed. Friends distanced. Jobs lost. The world is polarized, political and ugly. The discussion of starting an immunosuppressant medication feels portentous. I want to say the right thing. I tell him what I can—that current guidelines recommend we start treatment for his disease and monitor him closely in this anomalous time.2 I ask, with all this in mind, if he will take this medication.
He tells me he loves the beach. Before COVID-19, he had begun seeing a new girlfriend, but when he took her to the sand and rocks, the uneven terrain irritated his swollen knee. He asks if he will be able to walk at the waterfront again. I relate that the medication should help his knees. As Mr. H leaves the clinic, I think of the past few months, which emphasized that nothing is guaranteed and nothing should be taken for granted.
July 15
I call my husband, now 2,650 miles away, worried still, to tell him about my rheumatology fellowship.
I participate in weekly didactics. Like so much else, these too are altered by the pandemic. What was once a bustling room of engaged faculty, fellows, residents and students is now a Zoom meeting. National rheumatology conferences and key networking opportunities are now online lectures. I listen, I read, and I learn, but I miss the robust interpersonal engagement of prior times.
The majority of my outpatient clinic encounters consist of a telephone and a computer. I call patients with an interpreter on the telephone line and conduct my exam through a series of questions. I hope I am not missing something key that would be apparent on physical exam. Often, I lose the connection in the middle of the call. Other times, we cannot reach the patient. Many patients are afraid to visit the clinic for tests and imaging. There is something fundamentally missing, and we all know it.3
