Thinking Like A Rheumatologist

Arthur M. F. Yee

KEY POINTS

The diagnosis of many rheumatologic disorders is made clinically, and so a detailed medical history and thorough physical examination are unequivocally central to the initial evaluation of the patient. A strong knowledge base of rheumatology streamlines the diagnostic process, enabling quicker development of management plans.
Always treat the patient, not the laboratory results. Although laboratory, radiologic, and pathologic data can be very useful in the management of rheumatologic disorders, they should always be taken in the context of, and never supersede, the clinical picture. Appreciating the limitations of diagnostic tests optimizes their clinical utility.
Uncertainty is rife in rheumatology and must be accepted. Management decisions must often be made even when the clinical picture is incomplete or atypical, or when clinical data is unavailable or inaccessible.
Rheumatologic disorders are often variable in course and severity. The aggressiveness of therapy must be appropriate to the aggressiveness of disease, because both the treatment modalities and the illness carry potential dangers. The chronic nature of many conditions necessitates ongoing vigilance, even during periods of disease quiescence.
Better education of the patient, especially with respect to the nature of illness and to therapeutic goals and expectations, and trust between the physician and patient optimize compliance and outcome.

Hanging in my examination room are reproductions of two French impressionist paintings. The first is the famous A Sunday on La Grande Jatte by Georges-Pierre Seurat who pioneered the technique of juxtaposing small dots of different colors to create images that become apparent only when seen from a distance. Even then, however, smaller details can remain obscure and subtle. I use this painting to illustrate to patients how I often approach rheumatologic conditions. First, while I am generally called upon to evaluate a specific problem, I do not focus solely on one single “dot” but rather view it in the context of all the “dots” in order to see the whole clinical picture. Second, even if the picture is spotted with areas of fuzziness and uncertainty, it can still be fully appreciated and addressed with comfort.

FRAMING THE CLINICAL INVESTIGATION

Many rheumatologic conditions are clinical diagnoses and are systemic in nature, so it cannot be overstated that the skills most important to the rheumatologist are those that are also the most important to an astute internist. These include the ability to obtain an accurate medical history and conduct a thorough physical examination and to be comfortable with handling different organ systems. The review of systems, in particular, often provides crucial pieces of information that may not be spontaneously volunteered by the patient and also comprises a large part of my initial evaluations. This process, although seemingly exhausting, can be made very efficient by attaining familiarity with potentially relevant conditions. For example, an elderly man taking diuretics for hypertension who presents with recurrent acute inflammation of the first metatarsophalangeal joint need not necessarily be questioned for a history of sun sensitivity or a malar rash but should be questioned for a history of tophi or renal calculi. A young woman with a history of multiple osteoporotic
stress fractures should probably be asked about symptoms suggestive of malabsorptive states. A large fund of knowledge a priori improves the diagnostic process by generating pertinent questions and discarding irrelevant ones.

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