Donwload A Clinician’s Pearls & Myths in Rheumatology 2009th Edition PDF
Donwload A Clinician's Pearls & Myths in Rheumatology 2009th Edition PDF
by John H. Stone (Editor)
Important strides have been made in understanding the pathophysiologic basis of many inflammatory conditions in recent years, but rheumatology remains a discipline in which diagnosis is rooted in the medical history skillfully extracted from the patient, the careful physical examination, and the discriminating use of laboratory tests and imaging. Moreover, selection of the most appropriate therapy for patients with rheumatic diseases also remains heavily reliant upon clinical experience. Medical disciplines such as rheumatology that depend significantly upon clinical wisdom are prone to the development of systems of ‘Pearls’ and ‘Myths,’ related to the diseases they call their own, a ‘Pearl’ being a nugget of truth about the diagnosis or treatment of a particular disease that has been gained by dint of clinical experience and a ‘Myth’ being a commonly held belief that influences the practice of many clinicians – but is false. This book will pool together the clinical wisdom of seasoned, expert rheumatologists who participate in the care of patients with autoimmune diseases, systemic inflammatory disorders, and all other rheumatic conditions.
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 teacher also involves the ability to recognize and debunk Myths: those specious concepts and harebrained ideas that cling to the body of medical knowledge like gum to a shoe, despite being fundamentally wrong.Pearls and Myths are a substantial, ancient, and ever-renewed portion of the medical canon. When Hippocrates sat beneath the shade of his plane tree on the island of Kos and formulated aphorisms, he generated Pearls that continue to influence the fabric of medical practice down to the present day. Rheumatology fellows on the wards today will do well to recall Hippocrates’ Pearl that “A woman does not take the gout, unless her menses be stopped”. And even great clinicians are not immune to the unwitting propagation of Myths from time to time. No less an authority than Sir William Osler advocated the use of arsenic for the treatment of pernicious anemia.
The discipline of rheumatology is more conducive than most to teaching and learning by Pearls and Myths. Rheumatologists pride themselves on the idea that no subspecialty relies so heavily upon the history and physical examination – the laying on of hands – forrendering diagnoses. Astute rheumatologists can leap broadly to speculations on prognosis after an examination of only a patient’s fingers and hands. At the same time, rheumatology rivals any subspecialty for its array of diagnostic tests that appear arcane to outsiders: What are the clinical implications of a high-titer ANA with a speckled pattern? And the oligodot pattern?
A Clinician's Pearls & Myths in Rheumatology 2009th Edition
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