A Clinician's Pearls and Myths in Rheumatology
A Clinician's Pearls and Myths in Rheumatology is a rich assemblage of the clinical wisdom of expert rheumatologists from a whole range of specialties and nationalities. It examines the nuggets of wisdom, or ‘pearls’ gained from collective clinical experi
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John H. Stone Editor
A Clinician’s Pearls and Myths in Rheumatology
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John H. Stone, M.D., M.P.H. Director, Clinical Rheumatology Massachusetts General Hospital 55 Fruit Street / Yawkey 2 Boston, MA. 02114
ISBN: 978-1-84800-933-2 e-ISBN: 978-1-84800-934-9 DOI: 10.1007/978-1-84800-934-9 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009933269 © Springer Science+Business Media B.V. 2009 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper. Springer is part of Springer Science+Business Media (www.springer.com)
Preface
Once when I was an intern, an attending rheumatologist bemoaned the number of decisions he had to make when caring for a single complex patient. Which dose of prednisone? When to taper? Which steroid-sparing agent to add, or whether to add one at all? Was an ACE inhibitor a good idea in a patient with a serum creatinine of 3.5 mg/dL? When to employ Pneumocystis prophylaxis, and when to stop it? These struck me as highly interesting questions, but as an intern more concerned that my beeper might sound again any moment to signal my next “hit,” I took only passing note of the remark and evinced little sympathy for the beleaguered attending. At least he was going to get some sleep that night! Some years later, having differentiated into a rheumatologist myself, I pursued training in clinical investigation, wrote papers, conducted randomized clinical trials, and developed a stable of complex patients of my own. Only then did I recall the attending’s remark with empathy and observe just how few of the clinical decisions I made were based upon rigorous evidence. Indeed, even if the budget at the National Institutes of Health were once again to double within a short period of time and then to double again, the highly nuanced nature of rheumatic disease would yield to “Grade A evidence” on only a minority of important clinical decision points. In our discipline, there will always remain ample room for the keen clinical “Gestalt.” This inevitably brings chagrin to advocates of comparative effectiveness studies, among whom I count myself a member. The application of clinical evidence (when available) to major treatment decisions is critical to conscientious and effective patient care. But the dozens of smaller decisions that comprise the craft of medicine are still rooted in a clinician’s direct experience; in clinical intuition; in nuggets of wisdom handed down from mentors; and in tips imparted to practitioners by patients themselves. Rheumatology training and practice rely, in short, on the understanding and application of clinical Pearls. Further, becoming a good clinician and an effective
