A trio of master clinicians discussed the importance of physical exams, staying current on emerging science, responding to errors in judgment, and how COVID-19 has changed rheumatology during a live panel discussion on Sunday, Nov. 7. A recording of the session, Insights and Habits of Master Clinicians: A Conversation, can be viewed by registered meeting participants through March 11, 2022.
A key component in the diagnosis and management of rheumatic diseases is the physical exam, the panelists agreed, but characterized it as a dying art. Beth Jonas, MD, the Reeves Foundation Distinguished Professor of Medicine and Chief of the Division of Rheumatology, Allergy and Immunology at the University of North Carolina, said training for medical students and residents should include a greater emphasis on physical exams.
“You have to do a lot of exams, and in a very methodological way — very systematically — so that each time you do it you’re certain to see when there is something abnormal,” she said. “If you don’t do it all the time and if you don’t do it in a systematic way, then you’re going to miss something.”
During the COVID-19 pandemic, telehealth has proven to be a useful alternative to in-person healthcare delivery. But all three panelists questioned the role it will have in the future and underscored the importance of face-to-face interactions with patients.
“I don’t think we will be changing a biologic based on a telephone or a video call. That requires engagement with the rheumatologist,” said Gail Kerr, MD, FRCP, Chief of the Division of Rheumatology at Veterans Affairs Medical Center and Howard University Hospital, and Professor of Medicine at Georgetown University and the Uniformed Services University of the Health Sciences. Touching and healing go hand in hand, she said.
The practice of medicine requires mastering the technical aspects of patient care as well as the human aspects of understanding who the patient is, what their unique needs are, and what their understanding of their disease is, added Ronald Anderson, MD, author of Lessons Learned in the Care of Patients: A Rheumatologist’s Perspective. To be a clinician and not just a technician “doing the science of figuring things out,” the human aspect is essential, said Dr. Anderson, who listed three questions he prioritizes with new patients:
- What comprises the patient’s support system — who takes care of the patient and who does the patient care for?
- What makes the patient unique, including personal interests and family structure?
- How does the patient deal with adversity?
“Being sick with a disease is not an easy job, and we often are faced with patients for whom everything has gone wrong. It’s useful to go and identify how have they dealt with adversity in the past, how they have been successful,” said Dr. Anderson, who established the clinical rheumatology training program at Brigham and Women’s Hospital in 1971.
When a clinician makes an error in judgment — as all clinicians do at some point, even though physicians are taught they should be infallible, Dr. Anderson said — the panelists advised facing the error head-on to learn from it. Dr. Kerr said moving forward after an error may involve talking through the experience with a colleague.
“If you isolate yourself, you’re really going to go down the path of probably doing the same thing again,” she said. If a patient is harmed by the error, the clinician also should discuss it with the patient, she added.
To stay up to date on advancements in rheumatology, Dr. Kerr said she reads the premier journals in the field, attends grand rounds regularly, joins groups with interests common to her own, and engages with clinicians outside of her work cohort, among other activities.
Dr. Jonas often focuses her ongoing learning activities on the questions she receives from medical students, fellows, and residents in her clinic, as well as the patients she is treating.
“For me to really imprint that knowledge, I need to have a patient in front of me or a clinical problem I’m trying to solve,” she said.
Dr. Anderson also takes a patient-led approach to ongoing learning and advised clinicians to get involved with teaching rheumatologists in training.
“When you teach, you refine what your thinking is and it keeps you current,” he said. “You don’t have to be part of a med school faculty. You can teach in different avenues.”