Although as a medical student, rheumatology was always associated with an air of mystery and complexity to me — factors which might have aroused a younger me had they been associated with a member of the opposite sex – the specialty didn’t catch my eye at all as an undergraduate. To a medical student cruising for medical action in the 1980s, rheumatology wouldn’t have got as far as a first date.
Some medical specialties are cooler and sexier than others. Rheumatology could never really compete with the macho surgical cool of heading down to theatre to sew a hand back on or perform open heart surgery, or with the laid-back anaesthetic cool of medically paralysing someone, stopping their heart and lungs and then starting them up all over again (while reading the paper). Rheumatologists just didn’t wear leather jackets.
At that time, and despite its best efforts, my chosen specialty had an image problem. This wasn’t the fault of the rheumatologists; we just didn’t yet have the effective tools at our disposal to significantly impact on many of the diseases we treated. Nonetheless, this affected the attractiveness of our specialty to those choosing a career in hospital medicine and to our colleagues in other specialties.
Rheumatologists were seen by their colleagues as specialists who provided a baby-sitting service, albeit with lots of steroids, to the chronically unwell.
Our clinics were full of struggling patients for whom the treatments didn’t work and there were even special clinics to deal with side effects to the drugs we were prescribing (‘gold clinics’ were not as glamorous as they sound).
With my heart set on a career in the rapidly evolving, hi-tech and terrifically sexy specialty of radiology, I decided to get some general medicine under my belt before going for the interviews. Accidentally stumbling into a few months of rheumatology as part of one of the jobs, I surprised myself by beginning to like the job.
If I’m honest, the first thing I liked about it was that it seemed like a bit of a doss. In my first few weeks that summer, I found myself regularly clipping my on-call bleep to the net of the hospital tennis courts to hit a few balls with another member of the team waiting for ‘something to happen’. Although it was a false dawn (the job became much busier in the following weeks), I allowed myself to imagine a job that allowed a life outside medicine.
I liked the rheumatologists too. Most seemed to be very down to earth and have a genuine interest in the lives of the people they cared for. It seemed to be a specialty where there was at least some stuff could wait ’til morning. This allowed a measured commitment to the workplace in those I worked with that seemed to leave room for time with family, friends and for non-medical interests.
Porsche and 911s?
Although rheumatology is not as well paid as some other specialties, I resigned myself to the certainty that if I were to become a rheumatologist, I’d never own a Porsche. But then, neither would I have to drive it into emergency department in the middle of the night to unblock someone’s coronary arteries.
Rheumatologists also seemed to have a level of familiarity with their patients that I might have imagined an older, rural family doctor might have, effortlessly blending the catch-up familiarity of a chat between old friends with the medical business of dose adjustments, joint injections and referrals to orthopaedics. Whereas I now know that this approach and those relationships can take many years to develop, I liked the feel of it.
I also liked the mix of clinical problems coming along to the clinic; in a single morning you could see a patients with tennis elbow, rheumatoid arthritis, gout, osteoporosis, osteoarthritis, vasculitis, lupus and even a few of the worried well.
There was a nice mix of clinical medicine (where most of the clues are there from listening and examining), a bit of hi-tech imaging (with MRI, nuclear medicine) and a bit of nerdy hardcore science and immunology thrown in. Most of all though, I liked the patients.
Rheumatology patients are an amazingly resilient, patient and forgiving group of people. They are often cheerfully resilient while coping with the ravages and disappointments of living with a chronic disease, patient in their wait for slow- acting treatments to work (and where our clinics run behind!). They forgive rheumatologists when initial attempts to treat their disease fail (we’ve got to sometimes chop and change until we get the right cocktail for every patient), but always express gratitude when things go well.
Thankfully, rheumatology is entering a new era. The vast majority of patients with rheumatoid arthritis will do very well on treatment. The impact that modern treatments have had on joint damage means that for most, joint deformities are rare and, as a result, referrals to orthopaedics and plastic surgery have dropped. Outcomes from sometimes fatal connective tissue disease like vasculitis and lupus have improved dramatically and we are now very good at treating gout and osteoporosis and getting better at managing chronic pain.
Although I always thought that rheumatologists had reason to feel good about their role in the lives of their patients and their place in medicine, I think it is about time we added a little swagger to our ward rounds. I think I might just pop out and buy myself a leather jacket.
- Dr Ronan Kavanagh is a consultant rheumatologist at the Galway Clinic.