Polymyalgia rheumatica is a diagnosis often missed by the primary care physician. Asking a few pertinent questions, explaining the diagnosis, and assuring a worried older patient that their weeks or months of suffering will likely be gone within a few hours of starting prednisone feels great. Of course, I have to reassure them that this small dose of steroids will not be fraught with a host of side effects. I even ask the polymyalgia rheumatica patients to call in a couple of days just to leave a message that they’re feeling better. I think I feel better, too.
I don’t know about you, but the most common referral to my office is a patient with a positive antinuclear antibody (ANA) test who fears he or she has lupus. While some believe these worried folks take precious time in a busy schedule, I enjoy interrupting the history taking to reassure an anxious patient that more than 95% of patients with a “positive” ANA don’t have lupus and often exhibit no more than a “lab test in search of significance.” Their look of relief is priceless.
I can’t tell you that I always enjoy seeing fibromyalgia patients in consultation. The old adage that you can tell the fibromyalgia patients by the fact that the doctor feels achy and tired within a few minutes of meeting them is often true. However, I like seeing those patients who are willing to accept the concept of a symptom complex that is not a traditional organic disease. I think I have a pretty good spiel about the difference between subjective complaints and objective abnormalities, and the concept of a central pain processing problem related to sleep and mood disturbances. I like that I can educate the patient about the condition and help with their sleep and mood disturbances, but that there must be a great deal of patient responsibility regarding regular exercise, weight loss, and dealing with issues in their life. It is gratifying when some of these patients return to the office feeling better because they have been able to follow through on these recommendations.
Like many physicians, a great part of who I am is what I do. … Having a better than usual round of golf feels good, but it doesn’t compare to hearing the words “I feel so much better. Thank you, Doctor Birnbaum.”
Ultimate Medical Detectives
During my fellowship, Dr. Rodnan and Tom Medsger, MD, always encouraged referral of the most difficult diagnostic dilemmas. I think that many of our physician colleagues view rheumatologists as the ultimate diagnosticians. I can think of no greater satisfaction than making the diagnosis that several other physicians have missed. Whether it’s finding a small patch of psoriasis on a patient with joint pain and negative serologies or identifying urate crystals in a patient referred with “rheumatoid nodules,” I really like being the detective who solves the medical mystery.
