Friday, 14 Dec 2018

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Advice for Young Rheumatologists

You may not want my advice, but I’m going to give it to you anyway. 

Such are the words spoken by someone you’re usually not inclined to listen to, such as a parent, boss or “know it all” partner.  I happen to be none of these, so it may behoove you to consider these tenets as they may enhance your career in rheumatology.

I’ve written this think piece to hopefully guide those starting out in rheumatology; those who don’t yet have the numbers and mileage to be consider truly wizened by learning and mistakes. I’ve already written about how the last 30 years has taught me to be a better rheumatologist. 

Thus, the following advice is intended for younger rheumatologists, including fellows, recent graduates and those in practice for less than 7 years. This advice is born of years of observation on what happens as our careers progress from infancy (fellowship) to old age (retirement):

  1. Read daily or weekly - anything less is a half-baked plan to catch up on what you don’t know.  Have a plan for regular programmed learning (journals, podcasts, daily literature searches, medical library visits, weekly conferences, etc.).
  2. Don’t practice alone - While there are many good reasons to be a solo practitioner (small business, be your own boss, anti-socialism, etc.), these are best reserved for older and experienced rheumatologists.  Every great rheumatologist will tell you that while fellowship was wonderful etc., it does not compare to the wealth of what you will learn through years of practice – especially when you can learn surrounded by mentors and peers.
  3. Be known for One Thing - I’ve written a whole blog on this. Essentially you need to be a specialist amongst specialists. Why would someone want to need to see you?  You should stand out for something, attain excellence in one thing and what will ensue is a lifetime of excellence in many things.
  4. Know the definition of excellence - Famed coach Vince Lombardi said, “Perfection is not attainable, but if we chase perfection we can catch excellence.”
  5. Know what it takes to be a great physician - These are taken from past articles and tweets of mine:
    • The best doctors have two traits - curiosity and never giving less than 100%
    • Patients rate doctors highly if they have a personality and show they care
    • That one mouth of yours is outnumbered by your 2 ears. Great doctors are great listeners. 
  6. Doubt your physical exam skills - You haven’t been around long enough, nor done enough joint and MSK exams to be near ultrasound or MRI accurate.  If you’re not sure about joint swelling, ask a colleague, use the US (if you have one) but don’t order an MRI to supplant your lack of exam skills. The book “Blink” by Malcolm Gladwell purports that to be an expert and leader you need to do something 10,000 times. I think that’s true especially want to comes to joint exam. Those of us who grew up in rheum doing clinical trials were forced to do examine 66 joints repeatedly on every patient, every visit. Turns out that most of us still do the same today in practice, even for someone who has oligoarticular psoriatic arthritis in the hands only.  By contrast, most rheumatologists never do a 28 or 66 count joint exam and hardly ever take off the patients’ shoes or socks to examine the toes.  Try to be the kind of rheumatologist who is complete, detailed and comprehensive in doing all patient assessments.   
  7. You Don’t Need to write a Prescription - Don’t be compelled to start a biologic or DMARD in a patient who has no (or few) swollen joints. Often the impetus is the persistence or escalation of complaints or pain despite current DMARD therapy. You should worry more so if the patient is seronegative and has normal acute phase reactants. Know that biologics almost never be the first choice of therapy and when studied head-to-head, biologics have generally not shown themselves to be significantly more effective than methotrexate or other standard of care DMARDs. In general, all guidelines say that biologic use should only be considered with ACTIVE disease despite reasonable course of standard of care. You shouldn’t give a biologic unless you have a high certainty they will respond to this expensive biologic. But the real take home message here is do not use biologics when there is no firm evidence of synovitis (or active psoriasis or active colitis, etc.).  Address their other potential reasons for their pain, or mechanical dysfunction.
  8. Seronegative means, YOU-DON’T-KNOW - Sure there are 20+% of patients with rheumatoid arthritis (RA) who are seronegative and can be treated as any other RA patient. Studies have shown that seronegative patients often have more disease and damage than seropositive RA patients.  The reason is that they have to overcome the serologic (CCP+ or RF+) affirmation of RA by having with more RA features to be assured of having RA.  I would caution you to continually reconsider those seronegative “RA” patients who are doing well or who are in remission but remain on DMARD therapy. Their diagnosis should always be reconsidered. You should find new clues as to why their seronegative really or ultimately was PsA, Whipple’s disease, pseudogout/CPPD, cancer, etc.  Such patients should also be reconsidered for reduced or no therapy over time.  Often it is more prudent to re-think the diagnosis, manage pain and structural disease because of it, and assess for uncontrolled fibromyalgia and sleep disorders.
  9. Focus your efforts and worry in the first 2 years - I wish I knew 30 years ago that I should worry more about patient who is in their first two years of disease.  This is where good and bad practices and habits are established by both patient and physicians. This is where a disease trajectory is launched. This is where a correct diagnosis cuts through and helps and a misdiagnosis sets for a series of successive errors by you and other physicians. The first 2 years is when you have the best chance to show your worth as a rheumatologist and master clinician. I’ve seen too many early patients who show lapses in care or are noncompliant with visits, labs, or prescribed therapies. They may find reasons to not take methotrexate or other important therapies. And not surprisingly, when you look at them 10 years later it’s always ugly and the poor outcomes may not be changeable. They may become the train wreck you witnessed and have to live with.
  10. Misadventures of Prednisone - Nobody goes on prednisone without hearing the diatribe that says “prednisone is acutely wonderful and chronically dangerous - if you stay on this drug (in a dose greater than 5 mg a day) for months or more you will become fat, diabetic, hypertensive, with a greater risk of heart attacks, easy bruising, peptic ulceration, weak bones, fractures, common infections, severe infections, weird infections, hospitalization and premature death".  Make sure that the patient is more motivated than the physician to ultimately get off prednisone or other chronic steroids. 
Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
 
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Thanks Jack I particularly like the advice to listen. This is tougher than it seems and it took me a long time be a good listener and be comfortable with silence. Its important to not just throwing facts back to patients who are suffering. Sometimes pausing is powerful. Its all about establishing relationships.
Well said.....I really like your emphasis on the power of a pause, especially AFTER you put something out there that needs to sink in, have an effect, change a behavior etc. My best teacher in med School was a master at the pause and actually using that and body language to basically tell you what was important, which in his class was better than whats on the test!. Thanks LC!
Thank you Dr. Cush for your advice. The first few years in practice are quite challenging. MB