“I was hoping for good news, but now I am worried,” was the response of a 29-year-old patient when I suggested an oncology referral. He was four months into treatment of dermatomyositis and had experienced significant improvement of his muscle strength, CPK levels and interstitial pneumonitis, but a follow-up CT scan showed that his spleen had enlarged to 16 cm. A great uncertainty had entered this case. I had to tell him that there was a possibility of malignancy. All I could do right then was reassure him that he was not alone and that we would work together with the oncologist to determine what course of management was best.
Explore this issueJuly 2017
I am now in my ninth month of rheumatology practice. I was born in Nepal, where I went to college and medical school and did my internship. I came to the U.S. for my medical residency and rheumatology fellowship. I am very proud of my training program, which was great for me. However, in my transition to clinical practice at an academic medical center doing some patient-centered research, I quickly realized there was a gap between what I had learned in training and real-life experience.
It was during my internship that I became increasingly aware that ambiguous experiences with uncertainty, such as my patient with dermatomyositis, are part and parcel of rheumatology practice. However, it is now quite clear to me that the magnitude of this ambiguity was considerably more than I had imagined.
From Fellow to Practicing Rheumatologist
A year ago, in my final meeting with my fellowship director, we discussed some practical wisdom about the requirements for being a successful clinical rheumatologist. In a subtle, yet effective, tone, he told me that in making my transition to practice, I should keep certain things in mind, such as promoting a warm relationship with the office manager, attending and presenting at conferences, considering periodic 10-minute breaks throughout the workday to avoid burnout and active involvement with the Arthritis or Lupus Foundation.
In retrospect, this discussion was a good start; however, I had much to learn about the many facets and complexities of practice.
The first area was my relationships with my colleagues, staff, and most of all my patients. I was no longer a trainee. I was the attending physician with the ultimate practical and legal responsibility for my practice and patients. “The buck stops with me.”