RheumNow Podcast - Why We Love Rheumatology Fellows (8-7-20) Save

It's the 08/07/2020. This is the Room Now podcast. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. In this edition of the podcast, it's all about love.

It's all about our great respect and admiration for our new rheumatology fellows and our fellows who are continuing. Why? Well, we wrote two blogs about it in the past week, where we got a lot of advice from a lot of people who care. When I began my internal medicine residency many years ago, my chairman said, in this internship year, your education is gonna be like any other educational year, including elementary school or high school. You're gonna learn more in this one year than you ever learned before.

If internship was baptism by fire, well then rheumatology fellowship is the beginning of a slow burn. Everybody loves the rheumatology fellows, and that's really evident from the fact that I put out a call for hate. Got any advice for fellows? And I immediately got like 50, input advice, pearls, etc, from major people in rheumatology, all of which I posted, or most of which I posted in the two blogs that I'm going to talk about here tonight. Why?

Well, all of us. All of us aged rheumatologists, chairman of departments, program directors, people we've been mentoring for many years, we were once you, the new fellow. Moreover, you are about to become us. When you blink, you're going to have gray hair like me. You're gonna be a whole lot better at what you do.

The question is, again, what kind of career are you gonna have and how you're gonna get there? I think that's what our many mentors and KOLs, key opinion leaders, wanted to impart upon you. In you, have great and endless hope, and and that's for all our fellows, the second years, the third years, etcetera. So here are some pearls of advice from my friends, your mentors, and now your colleagues in the field of rheumatology. Doctor Sterling West from the University of Colorado says, always be humble, keep learning, be an advocate for your patients, don't get frustrated.

It's really important what you're doing at this stage of the game. He states, my hope for you, each of you, is that you end your career and you look back and say, was an excellent rheumatologist. Meaning, you put all that you had into it, that you had the right guidance and advice, and your path was exactly what you expected. I think that's a great aspiration. Eric Ritterman from Northwestern said, start every visit by asking the patient why they're there and what they hope to get out of every visit.

If you don't, you risk the possibility of not addressing their primary concern. This sounds really simple, but as you get into rheumatology, an increasing demand for you to get all that documentation, all those metrics, all those right questions. How long was your morning stiffness? How bad was it? You could spend twenty minutes on morning stiffness and go nowhere.

Morning stiffness is way overrated. Now, your attendings will argue with you about that, but I'm telling you, it really is, you gotta get to what it's all about, and what it's all about is why the patient is seeing you. Make sure you know that upfront, very sage advice from Eric. Doctor. John Kay, another great friend from UMass says, The most important thing to learn during your first year of your fellowship is how to be comfortable with uncertainty.

Meaning, I don't know, get really good at doing this, shrugging. Many of our patients present initially with an incomplete set of manifestations on some disease process that's not readily ascertained by history, physical, or even interventions in labs. Time is the most important component of the diagnostic process in rheumatology. This is echoed by Doctor. Jeff Sparks from Brigham and Women's who says, Tom, sometimes the best option is to admit you don't know, watch and wait.

Doctor Steve Paget from Hospital for Special Surgery in New York City says, never treat a test, always treat the person. And you should only order a lab test if it will change the diagnosis, prognosis, or therapy. You should always ask yourself, even with the simplest and least expensive test, do I really need this? Don't treat the chart. This is really about avoiding those sort of knee jerk processes that we can get sucked into that really go nowhere and just part of the, you know, the info cytosis that we generate when really you wanna be about accuracy and predictive, efficiency of the tests you order or the interventions that you, ascribe to.

Turns out these knee jerk practices are usually wrong and often quite wasteful. Hani Al Gahl Hani, I always screw up your name, El Gavalowi from the University of Manitoba. If you don't know Hani, got to get to know him. He's fabulous, great clinician, fabulous researcher, and he reminds us about the importance of research. He says, think about research carefully.

Is your fellows project or projects aimed at making you a well rounded clinician or is this a key step in your career as an investigator? It's a really important question. Often we do research during our fellowship part of the deal. But really, maybe you should be doing research because it is your future, it is your career. If it's just if it is going to be, you know, to be a key investigator, a researcher, then are you really prepared to pay your dues to get there?

That means not defaulting the clinical practice at the first sign of research failure, which will inevitably happen, especially early on in your research career. He's pointing out that research is tough, and hence a lot of people, everybody these days goes into clinical practice because it's easier, and that's where the moolah is. But you know who the real leaders are? You know who we look up to? We look up to Hany Elgabalowi and other researchers who spent their careers investigating the diseases we're supposed to know more and more about.

Again, it's a praiseworthy aspiration that few of you will make, but if you do, you're in a whole new league. Doctor Bonnie Bermas, my colleague at UT Southwestern says, if you see a four legged animal with black and white stripes galloping towards you, it's probably a horse wearing a zebra costume. What Bonnie's saying is that it is a different take on that old adage. If you hear hooves, it's more likely to be a horse, not zebras. But we see zebras.

We see a lot of black and white stripes coming towards us. And Bonnie correctly reminds you, still the most common things occur even when they have an uncommon presentation, a horse in a zebra's costume. It is the art and science of the differential diagnosis that makes rheumatologists unique. You know, most docs, they put down it's rheumatoid or it's OA and they're done. You can probably recite, when you're good at what you're doing, 10 different causes as to why someone has an asymmetric oligoarticular synovitis that has been going on for three weeks.

That's hard, but that's what a rheumatologist is all about. Doctor, Doctor Mike Hoeller is from also from University of Colorado says, learn today's state of the art treatment, but always consider how we could improve that in the future. Rheumatology is an evolving discipline that is rapidly changing with new scientific methods and insights, which makes it ever exciting and ever challenging. Mike reminds us that rheumatology has a firm history, and it's our obligation to build upon that and the advances that we will create in the course of our careers. Doctor.

Artie Kavanaugh from UCSD says, you're in fellowship to learn, and now's the time to push those that are instructing you and teaching you, you know, what's the deal? Always ask questions, and never end with questions. You should almost be like that five year old that will keep asking questions. Why that dose of prednisone? And push them to know not just the answer, but the source.

Is this based on research or is this just experience? Ask for the reference, go to the classic article from the 1980s that everyone forgot about but that you're going to know about, it's going to make you a much better clinician in the end. I'm going to end with a few cushisms, these are things that I threw in there with some support of my friends. I keep saying this but I can tell you I wasted too much of my career not recognizing that fibromyalgia underlies a lot of presentations. Meaning, think fibromyalgia first, I don't care what the presentation is, because they never come in saying, I have a sleep disorder and I'm fatigued and I have these tender points, they don't.

They come in with left ankle pain and swelling. They come in with weakness and inability to rise from a chair. They come in with, you know, horrible, horrific low back pain. They come in with classic rheumatoid arthritis with the synovitis, symmetric polyarthritis, and fibromyalgia, significant secondary component to what they have. So really you should be teaching primary care and teaching your colleagues, think fibromyalgia first.

I can't tell you how much time and expense it's going to save you. Often when this is not done, these people get the runaround and get exposed to drugs that will not help them and, and will delay their eventually getting better. You know, three things that you should think about at every visit, especially when the visit's going badly, meaning that you don't connect with the patient, it's become an ugly visit, it's going in all the wrong direction, it's combative, it's negative, whatever. Three things the patient needs at every visit: hope, goals, and rules. You gotta stop.

And when I'm having a hard time and getting frustrated, I think hope, goals, and rules. Oh, okay, now I'm refocused, now I can take what the patient's saying and put it into action that we'll end up with hope, goals, and rules. I threw a quote in, Success is born of bold choices, grand mistakes, and perseverance. A lot of our faculty said, you know, uncertainty is good, making mistakes is how you get there, meaning I've had to make a lot of mistakes and turn down a lot of good advice to get to where I am today kind of thing. Mistakes is where you need to go, and then you need to build on those mistakes to become the better rheumatologist.

My big thing is your one thing, And actually this was also put forward by Doctor. Dan Lavelle from the University of Cincinnati Children's Medical Center. Your career will be so enriched if you can find that one thing to focus your career on. Choose that one thing because it's worth working on it. And making progress in this area is both compelling and really important to you.

It eats at you, it's a thing that will keep you awake at night if you don't address it. I like the one thing attitude, meaning during your fellowship, the one thing I really focused on would be whatever. You know, it could be that, I actually talked to a recent graduate who said that during his fellowship, he focused on educating primary care. That was the one, his one thing. But you know what?

He didn't publish in the area. He didn't do any research in the area. He just got good at teaching primary care, which is great. But if really you wanted to have one one thing, that means you learn it all. You do the research in the area.

You compete for publication and notoriety in that area, that'll make you notable in your environment, in your city, in your university, and nationally, even as a very young person. And the other really important spin off to the one thing is that people who are good at that one thing also become very good at many other things and become leaders. And we need leaders, we need teachers, we need researchers. I put forward the concept, no man does an island, I think that was a play or a song, I'm not sure. The point being that you need to quickly, in the start of your fellowship, bond with others, affiliate with your colleagues, partner, conspire, be part of a group that's got a mission, whether that's with your other fellows, other faculty, the division lead, you know, other researchers.

Again, you can work on projects together, you can write together, you can develop new research, you can write chapters. Again, it just doesn't end. There's power in numbers. And going along for the ride, even when you don't feel like you're the leader in this area, is a fun thing and a very rewarding thing. And ultimately, you'll be having people jump on your bandwagon as you go further and further into rheumatology.

I had a quote long time ago on Twitter that said, Idealism and cynicism is easy. Meaning it's okay to be and easy to be polarized. Look at the news, it's all polarization. It's negotiating in between in life that's difficult, interesting, and very worthwhile. So that says that dealing with the gray is where you gotta sort of focus your efforts and be good at.

Many people, many practitioners live in the in between where there's no urgency to get it right. You don't wanna be one of these people. The equivocation can be endless and living in gray gets really comfortable, meaning, I don't know, maybe it could be methotrexate or it could be sulfasalazine. Why not, you know, no. You gotta get to certainty.

Problem is that getting to certainty, getting to black and white is very hard and it takes experience and it takes making mistakes to be really good at that. Which leads to my final quote which is maybe gonna be my epitaph, it's certainly my epitaph on my emails. It's a quote from the movie League of Their Own where the famous quote was there's no crying in baseball and by the way there is no no crying, sobbing or complaining in rheumatology but Jimmy Dugan played by Tom Hanks says, It's supposed to be hard. If it wasn't hard, everyone would do it. The hard is what makes it great.

We want you, the rheumatology fellows, to be great. You're our future. I want to end by a pitch for RheumNow. RheumNow is looking for a few good fellows to be reporters and faculty at our upcoming virtual ACR twenty twenty meeting. No, this is not for you newbie fellows, you PGY4s who are still trying to figure out your passwords, your parking spots, and what that Tomahawk goniometer is all about.

This is for second, third, and PGY9 fellows. If you want to be an ACR reporter, send me an email, jackcushroomnow dot com, and tell me why you think you'd be a great fit with our upcoming ACR twenty twenty effort. That's it for the podcast this week. You can go to the website and find many good things to read. We'll see you soon.