I was told before arriving in NYC that my mentor, Dr. Susan Goodman in Rheumatology at HSS, would be out of town this week which has turned out to be true (unlike in Liz's case). Instead of meeting with Dr. Goodman this week, I was put in touch with a Rheum research assistant, Kayte Andersen, who was very kind and understanding of my complete confusion of what was expected of me. Kayte gave me some suggestions of how to occupy my time this week. Based on her suggestions, I have attended some seminars and conferences, shadowed Rheum attendings and fellows, and shadowed an orthopedic surgeon.
I have attended a couple of seminars where the Rheum doctors get together to discuss patients including a "Transition" meeting which only occurs a couple of times a year. At this meeting, the pediatric Rheum doctors present some of their patients who have been under their care for years but who now are being transferred to adult Rheum due to their age. This meeting, which the patients themselves attend in part, is supposed to ease the transition for former pediatric patients who are used to the very hands on care of the pediatric doctors.
I also attended a conference on the use of MRI to diagnose subchondral insufficiency fractures and another conference on metabolic bone disorders. The metabolic bone talks were particularly interesting because they introduced the method of using DXA scans to measure TBS, trabecular bone score, which could be a better method of measuring bone quality clinically.
In addition to these meetings and conferences, I have also been shadowing some Rheum attendings and fellows. I have observed Dr. Ed Parrish as he meets with patients who are often referred to him due to "joint pain". During the patient exams, Dr. Parrish tries to determine the cause of the patient's joint pain, often trying to differentiate if the cause is mechanical or inflammatory. I have seen patients with rotator cuff tears, arthritis, and other mechanically-induced pain. However, I did see one patient, a relatively healthy male in his mid 40s, whose pain could not be explained by mechanics. He had been having various joint pain for over 20 years and was still searching for a cause. The biggest issue was that he did not want to try a drug treatment until he knew the cause. However, as Dr. Parrish explained to me, a lot of the inflammatory diseases cannot be diagnosed by a lab test but tend to be "diagnosed" based on symptoms and response to drug treatment. Dr. Parrish suspected that this patient had ankylosing spondylitis or psoriatic arthritis and suggested he start with the more conservative drug treatment to avoid side effects. The patient agreed to try the treatment seemingly in desperation due to the amount of pain he had. However, choosing a drug treatment plan (be it anti-inflammatory drugs, biologics, steroids, or anti-TNF) seems to be trial and error so it is likely that this patient will still be in pain for some time while they figure out which drug works best for him.
I have also shadowed Dr. Mark Figgie, an orthopedic surgeon, as he met with patients in the clinic. He also tends to see new patients who are referred to him due to "joint pain". However, his goal is to determine if the pain is mechanically included and, if so, if a joint replacement is needed as opposed to pain management or physical therapy. One thing I found interesting was that a couple patients came in with hip or knee pain, but Dr. Figgie was able to determine that the pain was actually due to back issues. Dr. Figgie also saw a few patients who had recently undergone joint replacement surgery. These patients had no issues and their new joints were working great. This was nice to see, but part of me kind of hoped that one of them would have an issue with their implant just so I could see what could go wrong. But I guess Dr. Figgie is too good of a surgeon for that to be common.
Lastly, I have also shadowed some Rheum fellows as they go on consult rounds. This has been interesting because I get to see patients with a wide variety of issues/conditions/ailments. Many of these patients have or are suspected to have Lupus or some kind of vasculitis, which is why Rheum is consulted for them. But there have been patients with breast cancer, pancreatic cancer, end stage renal disease, gout, rashes of unknown cause, multiple sclerosis, among many others. Going on these rounds has shown me how a patient's team and the consulted teams work together or try to work together to diagnose and treat the patient.
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