Medical Specialties - Rheumatology (15 Feb 2023)

SPEAKER_01 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal with live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. My name is Dr. Marilena Gianudi, and I am on the Training and Members Committee of the Royal College of Physicians of Edinburgh. So Dr. Ahmed, as I mentioned, is an ST7 rheumatology registrar based in Edinburgh. He has a specialist interest in medical education and has set up a module as part of the Internal Medicine MSE at the University of Edinburgh. He's also a trainee committee member of the British Society of Rheumatology. So, Mustafa, thank you for joining me today.

SPEAKER_00 1:19

Thank you as much. And it's a pleasure to be here for you.

SPEAKER_01 1:21

So I guess our listeners would want to know a little bit about what it's like to be a rheumatology registrar and what a typical day in your shoes might be like. So do you mind just talking us through that?

SPEAKER_00 1:33

So rheumatology is an outpatient-based specialty. So it may be more appropriate to talk as a typical week in rheumatology. So you will have your general rheumatology clinics where you see your pre-planned patients with routine appointments, but also depending on where you work and subspecialty interest, you may have clinics for connective tissue diseases, lupus, osteoporosis, gout, and other inflammatory arthritis. You also have the acute referrals that you see either as part of the acute derumatology clinics or inpatient referrals. So you see cases like suspected giant cell arthritis or patients presenting with acute monoarthritis or a flair of their disease. You also get to see patients with multi-system disease with unclear cause and suspicion of either connective tissue disease or vasculitis. So some units may have their designated dermatology ward, or others may just refer the patients. In addition, part of your work also is to lie out with the GP in terms of advice for suspected cases or management of their medication. You oversee day case treatment, and during the week also you get to have other meetings, multidisciplinary meetings with radiology, sometimes with pathology, and you get opportunities for teaching, research, and audit.

SPEAKER_01 2:54

So it sounds like no one week is like another, and you get a wide range of patients and pathologies that you'll see.

SPEAKER_00 3:02

Yeah, yes, exactly.

SPEAKER_01 3:04

And are there any practical elements to the specialty?

SPEAKER_00 3:07

So obviously, you have also the opportunity to get interventions, either joint injections, and there are also opportunity to do musculoskeletal ultrasound, which is this interesting part of our career also. Although it depends on the facilities available and where you work.

SPEAKER_01 3:24

And what was the main drive for you to go into rheumatology? What did you find interesting at the time that you were applying? And is that something that you've continued to find interesting, or have your interests changed as you progressed through training?

SPEAKER_00 3:39

I think the first spark of interest in rheumatology was back in my early training in internal medicine. And I remember one of the rheumaturgy consultants who had an excellent clinical acumen used to solve the most difficult cases. And I remember specifically a case who presented with pyrexia of a non-origin, and he had so many investigations with no clear cause found. But this consultant, just by revisiting the history, examining the patients, and I remember he also carried out pathogy tests, and the case turned out to have peschit disease with good response to treatment. And this was so inspiring. But to talk about two reasons to join derumatology, in my opinion, the biggest one for me is really the difference you can make to the patient's life. I want you to think and reflect just on your day-to-day activity, how many times and how many tasks you use your joints. And imagine then, in the presence of active inflammatory arthritis or joint inflammation, then how difficult and challenging the life will be. And just by starting the right treatment, the patient's life is transformed. They regain their function, they regain their quality of life, and this is so rewarding.

SPEAKER_01 4:52

I must say I sat in on a rheumatology clinic a couple of years ago, and one of the consultants had prescribed a patient depomendrium. And when they came back for a follow-up, they said the difference that they saw was pretty much instantaneous, and they were so happy with that outcome.

SPEAKER_00 5:06

Yeah, and it's not just really about the immediate effect of the medication. By putting them on the right treatment, you help them to reduce the risk of further damage to their joints or developing further comorbidities. But talking about treatment, this is also an important aspect of rheumatology, just thinking about the revolution and treatment in the last 25 years. It's so amazing how things dramatically change with the era of biologic treatment and other targeted synthetic therapies. So you can think of conditions like rheumatoid arthritis. There were so limited options 25 years ago with only conventional disease-modifying agents. And now you have so many options that you can help the patient to get the disease under remission. But also for those who are interested in research, there are still unmet needs, and there are so many exciting areas for research. One of the interesting areas right now is really trying to find predictors for response. So you can hopefully soon we can find a predictor where we can predict and start appropriate biologic treatment from the outset rather than giving them and just waiting for their response.

SPEAKER_01 6:15

I was just going to ask, obviously, rheumatology isn't necessarily a specialty that many trainees will come into contact with before they have the opportunity to apply for it for specialty training. How could you advise junior members of a medical team that might be interested in the specialty to kind of get involved with it?

SPEAKER_00 6:36

Yeah, so the first thing I would encourage them to try to get in touch with someone who works in rheumatology, see how the life looks like, but also familiarize yourself with the requirements to specialize wherever you work. So here in the UK, for example, so as part of the application, there are different components. And the highest weight in these components for application is showing commitment to specialty and also the clinical scenario. If we break this down in terms of showing commitment to specialty, as you mentioned, so some may have opportunity to work as in their Frutation Foundation year training, or they worked as a clinical fellow, but it's not mandatory. There are other ways to show your commitment, either to attend conferences, there are opportunities for tester days in rheumatology. So the British Society of Rheumatology offers a variety of tester days in different parts across the country. And I would also encourage people if you see interesting case in derumatology, lize with the rheumatology team and submit this case to a conference. And if there is an audit going on or a CRS, that's a great opportunity to involve and show your commitment. So, in terms of moving to the clinical scenario, I think it's a good idea to review the management of common conditions that you are expect to see as a registrar. So one of the most common conditions, like acute monoarthritis, it's expected that you may be asked during the interview about managing such cases. So a few tips here. Remember that the scenario assumes that you are a new trainee and you will not know everything. So know your limitation. Remember, there are other people around. You can ask your senior colleagues if you don't know how to aspirate the joint or ask for orthopedic. You can ask for ultrasound guided aspiration. Also remember that it's a holistic approach to the management. So remember the wider aspects of that management, pain management, referring patients to physiotherapy and managing their medications. So I hope this helps.

SPEAKER_01 8:44

Is there one that you think is particularly based at a level in which trainees could follow it quite easily?

SPEAKER_00 8:52

So there are a variety of things. So I mentioned that yesterday is just a good introduction. There are also the course skills in rheumatology. It's a quite introductory course related to rheumatology. And there is a case-based discussion conference. So these are things that I would recommend just to look at.

SPEAKER_01 9:11

If we just go back to what your day-to-day life looks like, I know that you mentioned that it's mostly an outpatient-based specialty, and I'm sure that a lot of trainees, you know, consider their work-life balance very important. But I'm also aware that you still do have on calls as a rheumatology registrar. What do your on-calls look like?

SPEAKER_00 9:32

So the rheumatology on call also depends on where you work, but most of the rheumatology on calls we don't cover night shifts. So it's mostly during the day. For example, where I work, our on-call is 9 to 6, and then you have also the weekend on calls. So it's a great specialty in terms of work-life balance. And during the on-call itself, you do see the acute referrals mostly with seeing patients coming with suspected giant cell arthritis or acute monoarthritis and allies in with the GP, like what I mentioned earlier.

SPEAKER_01 10:06

And if you do mind, without meaning to, you know, completely bore you with something that you possibly see every single day, but how do you go about assessing a patient for giant cell arthritis? Because I'd like to think that I speak for the majority of trainees. It's something that we'd like to think we always have in the back of our mind, but it's actually very difficult to know if it's an appropriate referral to rheumatology or not.

SPEAKER_00 10:27

So that's an interesting question. So for giant cell arthritis, see the referrals. And the most important thing here is that it's uh strictly above the age of 50, really. So we don't consider a diagnosis of giant cell arthritis below the age of 50. It's very rare. Things that present like giant cell arthritis below the age of 50 is mostly other differentials like anchor associated vasculitis, for example. But it's above age of 50. Patients presenting with new headache, mostly temporal headache with other features like scalp tenderness, jaw cludication, and occasionally visual symptoms. So these are really critical things to ask about and assess during the consultation. And also looking at the inflammatory markers as it's likely to be raised, the presence of normal inflammatory markers does not exclude the diagnosis but makes it less likely.

SPEAKER_01 11:19

And is it the kind of disease where any potential treatment should be started by a specialist? So after rheumatology review, or would you be happy if a you know general medic who is particularly worried that this might be gerrent cell arteritis start somebody on steroids before you're able to see them?

SPEAKER_00 11:35

Yeah, so it's really important here once you have a high degree of suspension of this condition to start the patient immediately on cortic steroids. And it's usually depending on whether they have visual symptoms or jocludication, in this case, you start with 1 milligram per kilogram, usually 60 milligram daily. Or if there are only symptoms of giant cell arthritis but no visual involvement or no jocludication, then you can start at a lower dose, usually 40 milligrams daily. And this is really important to start once you have high degree of suspicion clinically and raised inflammatory markers, because otherwise there is a risk of visual loss, which would be unfortunately irreversible. I want to highlight something here. Once you start the patients on predicolone, make sure you refer them urgently. If they have visual symptoms, then to ophthalmology. And if no visual symptoms, then refer them to rheumatology. They will be further assessed clinically and have temporal artery ultrasound or temporal artery biopsy done. So they are not lost from follow-up on very high dose of steroids unnecessarily.

SPEAKER_01 12:44

And I think because it's such an interesting specialty and the range of pathologies and presenting symptoms that you see is so, so wide. I know you mentioned an interesting case that kind of inspired you to get involved. But do you mind being that senior person who inspires someone else? So, what's been a case that has stood out to you in your years of training that you think, you know, what this was really interesting?

SPEAKER_00 13:09

Thank you. Are a variety of cases, but if I choose one case, I'll choose a case that I dealt with as a medical registrar during an ICF. But my rheumatology background helped me and proved really valuable here. So this was a case of a 17-year-old patient who was referred from the GP with dry cough, fever, and sore throat for nearly three weeks. And the patient did not respond to antibiotics and found to have very high CRP in the hundreds. And she also reported non-HE rash. And when she presented to the medical admission unit, as part of the triage, she had basic blood tests and she had throat swab, and she was found to have influenza positive test result, and her liver functions came back quite deranged with ALET in the south ends. My colleague who saw the patient first, knowing these results, he appropriately started to explore any reason for the derangement of the liver functions. And it turned out the patient took a significantly higher than the recommended dose of paracetamol during these three weeks with a high suspicion for accidental staggered paracetamol overdose. This was well managed, discussed with the hepatology team, with a plan for astyl cysteine imaging. She had blood cultures and virology screen done. And the patient was handed over to me to be aware of. But reviewing the data, I felt there are two things that don't really fit here. And one thing that influenza is unlikely to cause really daily fever for three weeks. And although paracetamol overdose is a very reasonable diagnosis here, but it doesn't really explain the full picture. So I started revisiting the history, and the patient presented and gave history of daily fever reaching 39. She had also argia, which moved from the rest to ankles, and she had no relevant travel or sexual history. Although her numbers were quite alarming in terms of the temperature 40, tachycardia, but she didn't look unwell or septic. And I found there are faint maculopapyral rash on the trunk. And she showed me photos of similar rash, but more widespread, and mainly comes during the spike of the temperature. So here there are so many differentials you can think of. And obviously, viral infection is on top of the list, as suggested also by the infectious disease. And when you think about this case, it's easy to get lost in the details. And it's important here to step back and look at the whole picture. And one of the very useful things is trying to give descriptors or what's called semantic qualifiers, summarizing the case. So if we summarize this case, saying that this is a patient who presented with scotidian fever, flitting argia, pharyngitis, evanescent thalmorpink rash or three weeks with deranged liver function, I can see now a pattern starting to appear. And the question follows: Are we really dealing with adult onset still's disease? To those who may not be so familiar with this condition, it's an inflammatory condition with high interleukins that present with a variety of symptoms, with no single test diagnose is this case. So it's a clinical diagnosis essentially. And one of the most commonly used is what's called the Yamaguchi criteria. And if you look at this, you'll find this patient takes most of these boxes in the Yamaguchi criteria. But one thing to remember here that this condition is a diagnosis of exclusion. You need first to make sure the patient doesn't have infection, malignancy, or other rheumatic diseases. As part of this condition, it's important to deal with the case that we have the same way treat for suspected paracetamol overdose. But at the same time, I wanted to make sure that this diagnosis is in the radar, as what I was more concerned about, that this part of this condition, as part of complication, these patients may go on to develop what's called macrophage activation syndrome. And this is a complication that can happen up to 15% of Still's disease patients, and that's a potentially life-threatening. And I was concerned in this specific patient because she started to have fever and very high liver functions derangement. So this condition, if suspected, then needs to give a high dose of steroid. So, in addition to the proper management plan that we had, I highlighted this patient to the rheumatology consultant and also I requested the ferritin test, which give you a positive direction into macrophages activation syndrome. This patient, despite receiving cysteine, there was no improvement in the liver functions, and she had the blood cultures back unremarkable. The virology screen came back all negative, while the ferritin test was very high, 28,000. So we were clearly going with this direction, with high triglycerides matching this condition. And once having all these results analyzing with the infectious disease and hepatology, it was clear that we are dealing with this case of Still's disease going through the phase of macrofiber activation syndrome. So she received missile prednisolone, three days of IV missile prednisolone pulse therapy. The next day, the rash improved and the temperature settled, and within the next few days, the ferritin almost back to normal. So this was a very interesting case, and there are so many things to learn from here. For me, was the importance of getting the scriptors and summary and getting the problem representation right. So important to step back and look at the whole picture and also realizing in such complex cases with other specialties.

SPEAKER_01 18:51

That's really, really very interesting. So thank you so much for that story. I guess the only thing that I'd like to go back to, not from a clinical point of view, because I would not want to discuss that in more detail with you, but you did mention that you were doing med on calls. So how does it work in terms of your training? Because obviously your rheumatology on calls are slightly different, and your day job is outpatient-based, as you said. How is the internal medical training alongside that? How does that work in rheumatology?

SPEAKER_00 19:20

So, rheumatology is a dual actually specialty or group one specialty where you have general medicine training in addition to rheumatology. And currently you do have pure rheumatology allocations, but it's variable really from region to region in terms of the exact details of this specialty. But you would be expected to participate in the acute medicine route and the hospital at night shifts as well. Some hospitals give you a pure allocation of rheumatology for two years, but you'd expect to have three years of rheumatology and one year of internal medicine. But expect to have the general medicine throughout training in terms of participating in the acute medical route.

SPEAKER_01 20:00

Okay, excellent. So I guess if I just sum up what we've been talking about for anyone listening. So we went through that rheumatology is mainly outpatient-based. Your rheumatology oncles tend to be non-resident oncles. However, you will have to do medical training alongside that. And the degree to which you do your internal medical training will vary from region to region. We've also covered how people can get involved with rheumatology before applying, and we've discussed some interesting cases. So before we wrap up, what would be your one piece of advice for anyone thinking about going into rheumatology as a career?

SPEAKER_00 20:42

So I would highly encourage them to speak to other rheumatology trainees and other rheumatology consultants, see how the life looks like, and try to get exposure to rheumatology. It's an exciting specialty. I've been working there for a few years and I would never think of other specialty. It's so exciting. I would highly encourage you to look at this also importantly. There is a good way to look at the specialty through the British Society of Rheumatology. There are resources for joining the specialty, starting rheumatology as a career. So I would highly encourage you to look at this.

SPEAKER_01 21:16

That's excellent. Thank you so much, Mustafa. Thank you for your time and thank you for all your words of wisdom. I'm sure that our listeners will be very grateful as well. And I hope that we can follow your career again sometime soon.

SPEAKER_00 21:28

Thank you so much, and it's a pleasure to be here. Thank you.