RheumThoughts: My Life in the Gray Zone Save

For someone who grew up in a family of engineers, where logic and definitive answers were absolute, I live comfortably in the gray zone of uncertainty.  

Rheumatology has been a field where the art of medicine is still practiced: symptoms and physical findings may overlap other disciplines, testing yields more confusion than answers, and many treatment guidelines are based on expert opinion rather than on data. What biologic to use next is anyone’s best guess, steroid tapers are a free for all, and clinical gestalt reigns.  

The past 2 weeks of being on hospital consults at the county hospital have really stretched my limits. I pride myself on keeping current on the data and being a pretty good rheumatologist, but the cases I encountered have humbled me. It was not unusual to be consulted on a rare case or a rare presentation of a disease. These consults required me to reach into the depths of my internal medicine knowledge, search the published literature and textbooks, call my colleagues from other institutions and consult with former professors and other specialists to make a diagnosis and formulate the best plan to help the patients.  

Rheumatologists are excellent at pattern recognition, but when the pattern does not make sense, it leaves us with an uneasy feeling. Many will revisit these difficult cases to see if there are clues missed. Sometimes, “ruling out” a disease will help hone the diagnosis. One of my mentors, Dr. Richard Brasington, had taught me “It is just as important to tell the patient what they don’t have when you don’t know what they have.” Often, patients are relieved to hear they do not have cancer, multiple sclerosis, or lupus even though their diagnosis is still unclear.  

So how do I live in this gray zone and not get frustrated?  I follow these 4 rules:

1. Regular followup. Unlike an episode of “House” where each medical mystery is solved in 45 minutes (plus commercials), difficult cases take time and careful attention. Regular follow-up is important as the disease process may progress with time and declare itself.  
2. Consider empiric trials of therapeutics. This may be helpful to draw out the diagnosis. Some patients with classic polymyalgia rheumatica symptoms do not have elevated inflammatory markers but respond beautifully with low dose glucocorticoids.  
3. Phone a friend. Sometimes you might be too close to a case that you miss what is in front of you. No one is expected to know everything. The rheumatology community is known for its camaraderie. We help each other. I have e-mail experts and key opinion leaders in the field to ask for help. They were more than happy to listen and offer advice. The cliché’s “No man is an island” and “It takes a village” applies to rheumatologists.
4. Sometimes, you just have to let the patient go. I have told some patients their issues are beyond my expertise and getting a second opinion may be helpful. I worry whether my own bias and limited knowledge might have blinded me to the diagnosis. 

Living in the gray zone can be unsettling for people who want clear cut answers, but for me, it is a way of life. If the answers were always black and white, I think rheumatologists would not be in such demand.