Spring 2017 (Volume 27, Number 1)

The Dilemma Rheum: You Used to Call Me on My Cell Phone*

By Tom Appleton, MD, PhD, FRCPC

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Actually, I called The Dilemma Rheum. Close enough.

When you start out in practice, no amount of preparation can make the transition from trainee to independent rheumatologist a completely seamless and self-assured experience. Of course, our training makes the transition feasible but, at some point, you must simply jump in–carefully–and learn by adapting to a myriad of situations from which you were buffered as a trainee. This is the natural order of things.

Yet, as rheumatologists, at the heart of what we do are people with rheumatic diseases. Our central purpose is to help, to heal and to provide the best care possible. In this context, there is simply no way to reconcile the difference between my zero years of experience in independent practice with that of the seasoned mid-to-late career-rheumatologist colleague in the next office. That is, if you’re lucky enough to have one nearby for advice and reassurance.

When the opportunity arose to participate in the Dilemma Rheum series, I jumped at it. Dilemma Rheum is aimed at people like me, who are starting out in practice. Providing care for patients is both exciting and humbling and many of the conclusions reached in the Dilemma Rheum reflect the excellent training of rheumatologists in the Canadian system, while others reflect the challenging nature of rheumatology where uncertainty is the rule, not the exception. So far, there hasn’t been a day (half-day?) in clinic without at least one case of “I’m really not sure what you have”. These are the cases my colleagues and I brought to the Dilemma Rheum sessions every four-to-six weeks for discussion with an expert–usually Dr. Janet Pope. Everyone on the call contributes their ideas too, which was interesting and beneficial; it was useful to hear how others at my stage in practice think about problems.

Sometimes there were clear answers with new ideas to take back to the clinic. For many cases, though, I came away reassured that rheumatology is unwaveringly complex, and we may never have all the answers. In many ways, this is what drew me to rheumatology in the first place. That complexity is both a blessing and a curse, but you will never lack stimulation in this profession. Recognizing the challenge of real-world rheumatology also inspires a healthy respect for what can be missed or misinterpreted. Hence, the opportunity to review cases with others in the field holds great value–even if that means giving up an hour or more of your late evening in Eastern Standard Time.

The ability to access senior colleagues’ experience to review the most difficult cases is a unique advantage of those in group rheumatology practices, but not universally available to many of us starting out. For the motivated senior rheumatologist looking for a project, a “curbside consult” hotline bling version of Dilemma Rheum (i.e., call when you need to) could be a good idea and the service would be even more valuable for new rheumatologists looking for a sounding board and/or advice in real time. While such blue-sky propositions may be too resource-intensive to be practical, Dilemma Rheum is available freely to young rheumatologists, and I highly recommend it to my peers. The real dilemma before us, though, is how to recruit and train more rheumatologists in Canada. With our senior colleagues in various stages of retirement contemplation and pre-contemplation, that could only mean one thing: we have work to do.

*Refers to "Hotline Bling" (2016) by Drake

Tom Appleton, MD, PhD, FRCPC
Assistant Professor of Rheumatology and Medicine,
Departments of Medicine and Physiology & Pharmacology
Scientist, Lawson Health Research Institute
Western University's Schulich School of Medicine & Dentistry
Rheumatology Centre, St. Joseph’s Health Care London
London, Ontario