I recently completed 30 years in private practice. Despite my boyish good looks, patients frequently ask whether I’m planning to retire. For many reasons, the answer is no. My retirement plan is still recovering from the crash of 2000, I don’t do well with large blocks of unscheduled time, and my wife says that she married me for better or worse—but not for lunch. Most importantly, I still truly enjoy the practice of rheumatology.
While running a small office has a multitude of hassles, all of that aggravation falls away as soon as I enter the examination room for that one-on-one interaction with a patient. I particularly enjoy new patient consultations, for that is when I must truly use my interviewing skills and diagnostic abilities. I like the fact that I have only an hour to decipher a patient’s history, perform a physical exam, review old records, make a diagnosis, explain my conclusions to the patient, and institute appropriate therapy. I must win the patient’s confidence and show that I know what I’m doing and am entitled to the trust that they place in me. After all, telling a patient that they have a chronic illness and that they need to take medications that can have serious side effects is not easy.
With this brief introduction, let me touch on some specific patient encounters we each face daily in our practices. While some are more rewarding than others, all bring me a sense of professional satisfaction.
Small Ministrations, Big Relief
I love to see gout patients. Perhaps that’s in memory of my late mentor, Gerald Rodnan, MD, who was an international expert on the disease. I have James Gilray’s 1799 print “The Gout” hanging in my office and ask patients if their pain feels like the mythical animal chewing on the bunion joint depicted in Gilray’s drawing. I also like to read to gout patients Sydenham’s classic description from my 1849 edition of Watson’s Lectures on the Principles and Practice of Physic, the general medical text of its day: “Place your toe in a vice and tighten it as much as you can. That gives a sense of rheumatism. Then give the instrument another twist and you will understand gout.”
I use the analogy of a bathtub in which the level of water is determined by whether the tap is too open or the drain is plugged up to explain the origin of hyperuricemia. I was an early advocate of teaching internal medicine residents about gout in the private practice setting. There’s nothing more fun that tapping a joint or olecranon bursa and then showing the resident monosodium urate crystal under polarizing microscopy. Most importantly, I love being able to promise a new patient that, before long, they will be free of their painful gout attacks by taking only a single safe and inexpensive pill per day.