What's in Your Toolbox?

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her [email protected].

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her [email protected].

When I was a resident, an attending physician in my geriatrics rotation always ended rounds with the question: "What did you put in your toolbox today?"

One of my favorite parts of my job is resident education. For a few months out of the year, I have an internal medicine resident shadow me. This provides me with an opportunity to teach, and perhaps inspire some of them to go into rheumatology, as my mentors in medical school inspired me.

But it is challenging to be responsible for someone’s learning. When I was in medical school I always appreciated the professors whose lectures catered to the levels of our medical knowledge – not talking above or below us. Now that I find myself in a similar position I am quite self-conscious of this. My goal is to teach residents information that will be most helpful for them in their general practice without wasting their time.

Since the bulk of internal medicine residency is focused on inpatient care, and since rheumatology is mostly an outpatient field, there is a fairly large gap between what residents know now and what they will have to know in a few short years. I have a short list of things that I think every internal medicine resident should learn.

– A good clinical eye has to be cultivated. The art of the physical exam is one of the few things that cannot be learned from books. I can think of a few eponymous physical exam findings and maneuvers specific to rheumatology – oh, to make Heberden and Bouchard, Gottron, Yergason, Finklestein, Patrick, and Schober proud – that can help any primary care physician make an accurate diagnosis. The neurological exam is also of some import in our field and so, thanks to Tinel, Phalen, Jendrassik, and Lasegue, I have a few tricks up my sleeve.

– The needle is our friend. Joint aspiration and injection are valuable tools in the primary care physician’s toolbox. A lot of patients present with knee osteoarthritis and it is an easy way to relieve pain, especially when there are comorbidities that preclude the use of NSAIDs. Also useful for when there is a question of septic arthritis on the wards and they can’t wait for the busy rheumatologist to get to the hospital after a long day at clinic, and the orthopedic resident is not cooperating.

– Back pain is ubiquitous. It is, in fact, one of most common reasons for an outpatient sick visit. But there are many different varieties of low back pain, and again, the arts of taking a good history and performing a good physical exam are relevant. I stress to the medical residents that imaging is not always necessary, HLA B27 testing is superfluous, and physical therapy is underutilized but extremely important.

– Know gout well. Much has been made of how poorly gout is managed in the primary care setting (though the numbers do seem to be improving). I still occasionally see patients who stop and start their urate-lowering drugs whenever they are in a flare – precisely not what they should be doing. If there is a relationship between the metabolic syndrome and gout, then shouldn’t primary care providers be just as familiar with the management of gout as they are with the management of hypertension, hyperlipidemia, and diabetes?

– Not all that glitters is gold. One of the more valuable lessons I hope residents leave with after a month with me is that an elevated ESR does not always mean PMR, and an elevated RF does not always mean rheumatoid arthritis. The differentials for these entities are slightly broader and need to be thoroughly investigated. Since primary care providers often order these tests I think they should also be able to interpret it.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her [email protected].