‘I was drawn to rheumatology because I was attracted by the challenge of the many systemic and essentially untreatable aspects of rheumatological conditions.’ — Ronald J. Anderson, MD
Rheumatology vs. Oncology
It’s useful to compare how the general approach to management differs between oncology and rheumatology. Both require a comprehensive program of care involving multiple medical and surgical disciplines aimed at a difficult disease. With cancer the natural course is to get worse and spontaneous remissions don’t occur. Reappearance of the disease is ominous and is dealt with aggressively. Therapy is aimed at the eradication of the process. Cures sometimes occur and are often the goal of treatment.
In contrast, most rheumatic disorders are potentially reversible and have a natural course marked by variability. Spontaneous periods of remission or improvement are often seen. This pattern of disease activity is most frequently observed in patients with systemic lupus and variants of spondylitis. Not all manifestations of these diseases do permanent harm, and mere observation is often a reasonable option. Therapeutic interventions are aimed at suppression of the process. Curative therapy seldom exists.
In contradistinction to cancer, in which the diagnosis is almost invariably certain and characteristically based on a definitive histological finding, many rheumatic diagnoses are essentially exclusion diagnoses. Laboratory studies, although helpful, are seldom conclusive. The exceptions are crystals in the joint fluid, positive blood or synovial cultures, and a few syndromes with a characteristic vascular or renal histology, such as giant cell arteritis.
You should become an expert in the exclusions that can masquerade as a systemic rheumatic disease. They often are more likely to respond to a specific intervention, and making the correct diagnosis is usually dependent on one’s skills as a competent general internist. Examples from my experience that still provoke warm memories are osteomalacia, endocrinopathies of several types and covert infections. Although these are relatively rare conditions, the benefit of the diagnosis is huge, and the rewards often dramatic. Be on the lookout. Sometimes, you must kiss a lot of frogs before you find a prince. Relish the thrill that occurs when one appears.
Making a Diagnosis
The most common conditions, rheumatoid arthritis and systemic lupus, have only classification criteria and not diagnostic criteria. In a sense, classification criteria are used in writing papers, but not necessarily for making decisions for a specific patient. Often, despite a thorough and complete evaluation, you can’t make a definite diagnosis. In a greater sense, this is a blessing, because once you make a diagnosis, the tendency is to stop thinking. Patients will often benefit from an uncertain physician, particularly one who is aware of their uncertainties.
