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The article by Dickstein et al on eating disorders in this issue of the Journal made me think about my experience long ago as an internist comanaging patients who had severe eating disorders.
As a rheumatologist, I noticed that these young women had a very high prevalence of fibromyalgia and associated visceral pain syndromes such as irritable bowel syndrome and interstitial cystitis. Because they had been experiencing fatigue and generalized pain, many of them had been tested for lupus. Since about 20% of young women may have a low-positive antinuclear antibody titer, some of these patients had been diagnosed with lupus, and some had been offered therapy.
Other factors reinforced their physicians’ appropriate concerns about possible connective tissue disease. For example, modest leukopenia is not infrequent in malnourished patients, and Raynaud phenomenon is common in young women. Bulimia is associated with gastroesophageal dysmotility, and some of these women had slightly elevated creatine kinase levels. These abnormalities were generally the result of over-vigorous exercise, ipecac use, emesis, and hypokalemia. However, myositis or scleroderma overlap syndromes had occasionally been diagnosed in some patients, especially when the severity of the primary eating disorder was unappreciated.
Many, including myself, have written about the strengths and limitations of evidence-based medicine. We routinely make both evidence- and experience-based clinical decisions, often with little time to reflect on the exact reason for each decision. As I think back on my stint in the eating disorders clinic, recalling individual patients and lessons learned, I am struck by how observation-based my management of those patients was and how those experiences have stuck with me.
Reflective clinical care (also known as anecdotal experience) can have a lasting impact on the way we practice. Twenty-five years later, I still think about eating disorders when I evaluate young women who have severe fibromyalgia.
The article by Dickstein et al on eating disorders in this issue of the Journal made me think about my experience long ago as an internist comanaging patients who had severe eating disorders.
As a rheumatologist, I noticed that these young women had a very high prevalence of fibromyalgia and associated visceral pain syndromes such as irritable bowel syndrome and interstitial cystitis. Because they had been experiencing fatigue and generalized pain, many of them had been tested for lupus. Since about 20% of young women may have a low-positive antinuclear antibody titer, some of these patients had been diagnosed with lupus, and some had been offered therapy.
Other factors reinforced their physicians’ appropriate concerns about possible connective tissue disease. For example, modest leukopenia is not infrequent in malnourished patients, and Raynaud phenomenon is common in young women. Bulimia is associated with gastroesophageal dysmotility, and some of these women had slightly elevated creatine kinase levels. These abnormalities were generally the result of over-vigorous exercise, ipecac use, emesis, and hypokalemia. However, myositis or scleroderma overlap syndromes had occasionally been diagnosed in some patients, especially when the severity of the primary eating disorder was unappreciated.
Many, including myself, have written about the strengths and limitations of evidence-based medicine. We routinely make both evidence- and experience-based clinical decisions, often with little time to reflect on the exact reason for each decision. As I think back on my stint in the eating disorders clinic, recalling individual patients and lessons learned, I am struck by how observation-based my management of those patients was and how those experiences have stuck with me.
Reflective clinical care (also known as anecdotal experience) can have a lasting impact on the way we practice. Twenty-five years later, I still think about eating disorders when I evaluate young women who have severe fibromyalgia.
The article by Dickstein et al on eating disorders in this issue of the Journal made me think about my experience long ago as an internist comanaging patients who had severe eating disorders.
As a rheumatologist, I noticed that these young women had a very high prevalence of fibromyalgia and associated visceral pain syndromes such as irritable bowel syndrome and interstitial cystitis. Because they had been experiencing fatigue and generalized pain, many of them had been tested for lupus. Since about 20% of young women may have a low-positive antinuclear antibody titer, some of these patients had been diagnosed with lupus, and some had been offered therapy.
Other factors reinforced their physicians’ appropriate concerns about possible connective tissue disease. For example, modest leukopenia is not infrequent in malnourished patients, and Raynaud phenomenon is common in young women. Bulimia is associated with gastroesophageal dysmotility, and some of these women had slightly elevated creatine kinase levels. These abnormalities were generally the result of over-vigorous exercise, ipecac use, emesis, and hypokalemia. However, myositis or scleroderma overlap syndromes had occasionally been diagnosed in some patients, especially when the severity of the primary eating disorder was unappreciated.
Many, including myself, have written about the strengths and limitations of evidence-based medicine. We routinely make both evidence- and experience-based clinical decisions, often with little time to reflect on the exact reason for each decision. As I think back on my stint in the eating disorders clinic, recalling individual patients and lessons learned, I am struck by how observation-based my management of those patients was and how those experiences have stuck with me.
Reflective clinical care (also known as anecdotal experience) can have a lasting impact on the way we practice. Twenty-five years later, I still think about eating disorders when I evaluate young women who have severe fibromyalgia.