Rheumatology and Me

-Written by Dr. Ripudaman Singh, MD, PGY-2 Internal Medicine, Saint Peter’s University Hospital/Rutgers Robert Wood Johnson Medical School Program

I flipped the “MD with patient” exam room flag and entered to see the 2:30 pm appointment. A young lady was sitting tensely on the examination table and her young child engrossed on her E- tablet. However, my attention wasn’t immediately on her gaze or words; it was fixated on her hands. Her hands, etched with traces of nervousness, pain, and worry, spoke volumes. This was my first chronic Rheumatoid arthritis patient who needed my help and needed it urgently. She
came to the resident-run clinic after months of seeing a doctor. She lost her husband to illness, her job and subsequently her health insurance. She reported being diagnosed with arthritis but
couldn’t receive treatment months ago due to the turmoil in her life. I felt the pain in her voice and the helplessness in her gestures. We went ahead and decided to tackle this together.

I was intrigued yet worried. I never managed a rheumatoid arthritis patient prior. It was new to this freshly minted intern and I had doubts. Doubts about using big medications, doubts about their efficacy and doubts about her adherence. My clinic attending that day told me the story of her mother who battled RA and with her first-hand experience, that day we took it upon ourselves to manage her medical condition. I learnt a lot that day but not enough.

Primary care medicine sees a good amount of rheumatology. The number adds up. But does the required knowledge or skill set stand a similar stance? I was not surprised to see studies performed at academic medical centers in the United states where residents reported a lack of confidence in the practice of Rheumatology (1). This confidence was lower than in the fields of Cardiology, Gastroenterology and Pulmonary medicine in a study done in Canada (2). I read up on suggestions. Suggestions that have been hypothesized but partially implied. I say partially because the effect has yet to kick in fully. Be it the required knowledge to interpret the ANA titers, the art and workup before the referral and knowing what early Rheumatoid arthritis affected joints will look like rather than the one which we are shown in the textbooks. All these and many other queries continue to be rather quite visible to me as a medicine resident.

The young lady in the clinic is not the only reason I am writing this today. She was one of the many who enlightened my clinic panel of patients. The disablement seen in these cases is much higher than the practical training available to prevail over it in most healthcare settings. Studies have tried co-relating In-training exam scores with the confidence in residents’ rheumatology practice but have consistently concluded that those alone don’t work (3). The same study mentioned above showcased how the impact of rheumatological training is far greater than other comparable specialties (2). So as a part of the curious personality types, I feel it’s a discussion which needs to be on the forefront. Lack of access to quality rheumatological healthcare provision continues to widen and continues to surface frequently (4).

So, what’s the next step? As a resident, I believe the solution might lie in advocating for early and more comprehensive access to rheumatological training especially for community settings. Whether through in-person experiences or via online platforms from advanced rheumatology centers, providing residents with the necessary skill set is crucial. The natural follow-up query pertains to the scarcity of workforce and already strained resources. But in the words of Nelson
Mandela:

“Education is the most powerful weapon you can use to change the world.”

Let’s start small, but let’s initiate this change swiftly.

References

‌1.He L, Didem Saygın, Leverenz D, Quimson L, Martin S, Ko K. A single center pilot study:
assessing resident needs and faculty perceptions to improve training in rheumatology. BMC
Medical Education. 2023;23(1). doi:https://doi.org/10.1186/s12909-023-04336-8

2.Katz SJ, Oswald AE. How confident are internal medicine residents in rheumatology versus
other common internal medicine clinical skills: an issue of training time or exposure? Clinical
Rheumatology. 2011;30(8):1081-1093. doi:https://doi.org/10.1007/s10067-011-1715-4

‌3.Leverenz DL, Eudy AM, Criscione-Schreiber LG. What do internal medicine residents know
about rheumatology? A needs assessment for curriculum design. Clinical Rheumatology.
Published online November 17, 2020. doi:https://doi.org/10.1007/s10067-020-05506-5

4.Miloslavsky EM, Bolster MB. Addressing the rheumatology workforce shortage: A multifaceted approach. Seminars in Arthritis and Rheumatism. 2020;50(4):791-796. doi:https://doi.org/10.1016/j.semarthrit.2020.05.009. Available from: https://www.vecteezy.com/vector-art/628327-knowledge-flat-design-business-concept-cartoon-
illustration