The Learning Curve

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.

When I graduated from my fellowship program, I felt insecure and unprepared to start private practice. It was intimidating to no longer have a preceptor to guide my clinical decisions.

But, as I suspected, the learning curve is pretty steep. Going from seeing patients 3 half-days a week (as mandated by the American Board of Internal Medicine) to seeing patients 5 days a week has been a blessing in disguise.

I am thankful that I practice with some of the best in the community in Providence, R.I., and they are always available to discuss difficult cases.

These are some of the pearls I’ve learned in my first 2 years of practice. I am sure we all have our own lists.

1. We all practice differently. The length of time to treat polymyalgia rheumatica, the preferred time interval before changing methotrexate dose, the next step after your 3-mg/kg dose of infliximab does not work, even the decision to diagnose someone with rheumatoid arthritis vary among rheumatologists.

2. When an elderly patient presents with an elevated erythrocyte sedimentation rate, but your suspicion for polymyalgia rheumatica is low, a serum protein electrophoresis and a chest x-ray can be lifesaving.

3. Sarcoidosis is not that rare. Although we often think of it in the setting of classic Löfgren’s syndrome, I have seen it present as an isolated large joint monoarthritis. When the chest x-ray is negative, I will get a chest CT scan (although you have to be prepared to duke it out with the retired radiologist on the other end of the insurance company’s prior authorization line telling you that your case does not meet criteria for a chest CT).

4. Hydroxychloroquine can unmask psoriasis. I have seen it about three times now, although I know some rheumatologists who do not believe me.

5. I have often enough seen negative temporal artery biopsies, and synovial fluid in which I cannot find monosodium urate crystals. These never fail to disappoint me.

6. The 5-mm cutoff for the purified protein derivative test is just as sensitive as the flashy new interferon-gamma release assay tests (that is, QuantiFERON-TB Gold and T-SPOT). And because my concern is not to diagnose tuberculosis but to avoid its reactivation in someone who will be getting a biologic, I care much more about sensitivity than specificity. Better safe than sorry.

7. Syphilis can present with oral ulcers. Syphilis is a great mimicker and should be part of the differentials for oral ulcers, especially when the oral ulcers come with skin lesions that do not look vasculitic. Case in point: I saw a patient with erythema multiforme and oral ulcers. Several of his doctors thought it was Behçet’s and referred him to me. My colleague suggested rapid plasma reagin testing, and indeed, syphilis is what it turned out to be.

8. À propos of No. 7: Wearing gloves can save one a pain in the keister. I know that the skin lesions of syphilis are "teeming with spirochetes," to quote one relic of an infectious diseases doctor who was a pioneer of diagnosing and treating syphilis in the day. And because I touched my patient’s erythema multiforme with my bare hand when I was examining him, I had to get prophylactic penicillin G: 4 cc of cloudy, milky, cold goodness divided between my glutes. Not fun. I could not sit comfortably for a few days.

9. As much as I hate waste and unnecessary testing, some patients are not satisfied until they get every single joint imaged. I can turn blue in the face explaining that it is unnecessary and irresponsible, and they will still demand it. This leads to patient dissatisfaction. But if I must choose between being responsible and being liked, I choose the former.

10. Poststreptococcal arthritis is a real problem, distinct from rheumatic fever. But there is not much good quality literature on this problem.

11. A bonus! À propos of No. 10: There are many, many, many things in our field that lack good quality literature. And with that, dear readers, we come full circle to pearl No. 1!

Dr. Karmela Chan is a rheumatologist in private practice in Pawtucket, R.I.