What bedside skills should the modern rheumatologist possess? Part I. The Basics.

Abstract

The hands-on aspect of rheumatologic practice serves to balance its more cerebral features with the everyday necessity to touch patients to assess their condition, obtain samples for diagnosis, and deliver therapy, all cementing the important bond between patient and physician. Factors over recent years, ranging from the intercession of the electronic medical record to COVID have weakened this bond, which we must restore if the practice of rheumatology is to return to previous levels of satisfaction. We review herein, in two parts, the many ways rheumatologists may interact physically with patients, with hope that pursuit of these measures can enhance satisfaction of physician and patient alike. This first installment reviews those simple skills in place before more involved technical bedside skill began to evolve over the last half century.

Introduction.

Rheumatology was certified as a specialty of internal medicine by the American Board of Internal Medicine (ABIM) in 1972, although many doctors called themselves rheumatologists dating to the early part of the last century and the scope of what constitutes rheumatologic practice was well established by time of ABIM certification [1]. The young certified subspecialty was barely a decade old when two of us (RWI, KCK) chose it for our career, attracted by the unique balancing combination of skills – call it head and hands – required for successful practice. We must use our head to discern and analyze the nuances of the often tremendously complicated clinical situations we face but must also be good with our hands, both to assess the physical manifestations of our patients’ presentations and to direct accurately a needle into musculoskeletal structures to obtain fluid for analysis and deliver medication for palliative treatment. In our fellowships, the same two became the first American rheumatologists to be trained by another rheumatologist in arthroscopy, a procedure not new to rheumatology but never widely practiced. As we were embarking on this venture, Bill Kelley – RWI’s chief and mentor to our arthroscopy mentor Bill Arnold – stated in his 1987 address as President of the American Rheumatism Association (now American College of Rheumatology) that to make our subspecialty more attractive to students and trainees “we need to expand the specialty of rheumatology to cover some of the peripheral areas which now are largely ignored and sometimes poorly handled. This would include …the use of certain technical procedures which are appropriate to our specialty” (our emphasis) [2]. We took these words as marching orders.

Much has happened in rheumatology over the ensuing four decades. Demands on the head have expanded. There are new diseases (e.g., IgG4 disease, checkpoint inhibitor complications, nephrogenic systemic fibrosis, cocaine-levamisole induced vasculitis and leukopenia, and monogenic autoinflammatory diseases, among others) and an expanded focus on others (e.g. scleroderma, immune-mediated coagulopathies, even psoriatic arthritis and gout). Available treatments have exploded, often much more effective but also more costly, complicated, and possessing their own potential sometimes devastating complications. Some of the sickest patients in the COVID pandemic had manifestations that proved to be immune mediated, managed by some of these same specifically targeted biologics rheumatologists use, with rheumatologists called in to assist with diagnosis and management [3]. Frank rheumatic diseases have emerged de novo post-infection [4]. Demands for the rigor of “evidence-based medicine” have left practitioners sometimes doubting their own clinical intuition and reasoning based on experience, amplified by outside scrutiny of their practice. The now ubiquitous electronic medical record (EMR) has doctors expending time and energy to adapt to each new iteration and navigate existing hoops while seeing their skills at composition of a reasoned and literate clinical note replaced by a demand for completed checklists. And instead of application of those skilled hands to assessment and palliation, they spend much time typing data into the EMR, facing a screen rather than the patient. Judgement of a suspected musculoskeletal anomaly is often relegated to a referral for an imaging procedure much like the cardiologist opts for the echo over careful auscultation. Bedside interventions are called into question, with intraarticular glucocorticoid for knee osteoarthritis found to have harmful effects on cartilage [5], and hyaluronic acid ever questioned over equivocal clinical data, occasional side effects, and cost [6], although the disfavor with which some professional societies have shown toward use of the compound has been called into question [7]. One consequence is that patients are touched less by their doctor, patient satisfaction diminishing in concert [8,9], so evidently amplified by the virtual encounters dictated by the COVID pandemic, as well as other adverse impacts [10].

So, as we find ourselves more than two decades into this new century, what should the often overtaxed rheumatologist be trying to do to better serve his/her patients? We propose a return to the balance that once made this such an attractive specialty. Sure, some of our often-bewildering multisystem illnesses might seem attractive to the young cerebral trainee looking for a challenge, but the long ride of a satisfying clinical life isn’t spent on a roller coaster. We think a much saner and more fulfilling career can be accomplished by re-acquiring and practicing some of the hands-on clinical skills acquired and mastered by many rheumatologists over the years. So that we can focus adequately on each skill, we have split the descriptions into two parts: the basics, long a part of rheumatology practice, and on the more technical procedures which have emerged over the past half century. With the rest of this article, we shall go through those basics, and, where relevant, describe specifics on how they might be pursued.

Methods.

For our review, we relied heavily on our collected recollections of a combined 83 years of post-training clinical practice plus our own personal libraries. To assure that we had not missed key advances or insights, we utilized search engines Scopus, Web of Science, and Pub Med, inputting terms “physical examination”, “clinical photography”, “arthrocentesis”, “polarizing light microscopy”, and “nailfold capillary microscopy”. We crossed these terms with “rheumatology”, considered publications over the past 5 years, reviewed the results (528 cittions on PubMed, 307 on Web of Science), and incorporated them into text and reference list when new findings expanded our own understanding.

Physical exam.

No subspecialty of internal medicine relies more on the physical exam than does rheumatology. Perhaps because our diseases so frequently involve joints, there are all those moving parts and all those parts are all a little bit different. While we don’t need to assess any particular joint with the anatomic precision sought by the orthopedist, we’d better come away with a notion of why it’s hurting and not moving right. Numerous guides to the musculoskeletal exam have been published over the years. Many rheumatology fellows of our (RWI’s, KCK’s) era received Hoppenfeld as a perk from a drug rep, and the superbly illustrated volume has served us well [11]. Our other standby, which we had to purchase, Polley and Hunder’s slim volume, which has not been updated since the 1978 2^nd edition, contains tips on interviewing rheumatology patients, and is available online [12]. A web-based curriculum to teach the musculoskeletal exam has been developed [13]. Poor knowledge of musculoskeletal anatomy and inaccurate assessment of same leads to overutilization of expensive imaging, results from which can sometimes mislead. Senior rheumatologists lament fading familiarity with musculoskeletal anatomy and implore for its teaching [14]. Such deficits can be addressed by continued self-study, even using one’s own anatomy as a guide [15]. Essentials of the rheumatologic musculoskeletal exam have recently been described concisely but in detail [16]. And the rest of the body needs our attention, too, as our diseases don’t respect boundaries. So, we’d better have our ears out for crackles, murmurs, rubs, and gallops, with fingers attuned to adenopathy, masses, organomegaly, edema, and eyes focused all that stuff on the surface. Degowin and Degowin, first published in 1965 and now in its 11th edition, is an excellent compact compendium of physical findings that might be encountered in all organ systems, and their significance [17]. The nervous system can be affected by a number of rheumatic processes, and proficiency in its assessment is a valuable skill. A slim handbook put out by Her Majesty’s War Council in the middle of World War II to aid battlefield assessment of nerve injuries - Aids to the Examination of the Peripheral Nervous System – is in its 5^th edition and remains a very useful guide to that often-difficult exercise [18]. Finally, the physical exam is a chance to bond with the patient, who gains satisfaction from being touched as well as talked to. Guidelines for performing the musculoskeletal exam virtually have been proposed [19], but it’s hard to see how this would be a very satisfying experience for either patient or physician

Clinical photography [20].

With the excellent cameras in today’s cell phones, it is no longer necessary to call in a photographer or carry an expensive SLR to record interesting clinical findings. A recorded image can be shared with a colleague later, uploaded to the patient’s EMR, and published if the patient’s case is sufficiently memorable and unique. Comparison images at a later visit can help assess clinical changes. Lenses that clip on the phone are available and can provide a magnified view. Video recording capabilities make possible documentation of dynamic findings. A simple blue treatment towel provides an excellent background for the finding being photographed.

Nailfold capillary microscopy.

A magnified view of the array of hairpin capillaries at the base of the nail can detect perturbations that have diagnostic and even prognostic significance [21]. Abnormal capillaries in the patient with Raynaud’s indicate the process is more than simple exaggerated vasospasm and may evolve to a rheumatic disease. Abnormal capillaries in the patient with a positive ANA indicate a rheumatic process may indeed be brewing. Abnormal capillaries in a patient with an elevated CK indicate an inflammatory myopathy is a very strong possibility. Capillaroscopic findings in scleroderma may serve as biomarkers for end organ involvement and progression [22]. The exam can be conducted with a simple ophthalmoscope set to +20 diopters, with a little immersion oil or clear lubricating jelly on the base of the nail to counter diffraction by the skin overlying the capillaries. Dermatoscopes, dedicated illuminated magnifiers used by dermatologists to examine the intricacies of skin lesions, are well suited to nailfold capillaroscopy. One model incorporates a polarizing filter that eliminates the need for oil or lubricant. Each new rheumatology fellow at the University of Michigan (RWI’s institution) receives a Dermlite DL100 (Figure 1a) during orientation. At our institutions, training on how to use these ‘scopes is informal, but a formal curriculum has been described [23]. Magnifying lenses exist that can be clipped onto a cellphone turn the phone’s camera into a suitable capillaroscope - still requiring oil or lubricant - with the advantage of being able to record any pathology seen, producing an image that can be uploaded to the EMR. More sophisticated attachments to the cell phone have produced an instrument capable of monitoring movement of red cells within nailfold capillaries [24]. An inexpensive USB device has been shown to be comparable to videocapillaroscopy for assessing detailed abnormalities of nailfold capillaries (Figure 1b) [25].

Figure 1.

Instruments for bedside nailfold capillaroscopy. a. Dermlite DL 100 with polarizing filter (3Gen Inc., San Juan Capistrano, CA); b. Bysameyee HD 2MP USB Microscope (Bysaneyee, trademark of Shenzhen Shengyi Electronic Commerce Co.,Ltd, Guangzhou, China). Similar product to that described in reference 25.

Arthrocentesis.

The grandaddy of rheumatologic procedures. Doctors have sought to get fluid out of swollen joints since meso American Indians inserted hollow quills and thin bones into swollen knees to drain them in the 16^th century [26], or maybe Hippocrates got there first (Figure 2) [27]. The late Joseph Hollander popularized “synovianalysis” as “liquid biopsy of the joint” [28], and to this day, much can be learned from synovial fluid, even before the lab comes back with the numbers [29]. But the good Dr. Hollander also earned the sobriquet “der alte Gelenkspunktierer (the old joint sticker)” for his liberal application of intra-articular glucocorticoids to various joint scenarios [30]. Prior to Mayo’s George Thorn’s successful therapeutic injection of newly available “compound F” (now called hydrocortisone) into an arthritic joint, physicians had injected such compounds as petrolatum, iodized oil, lactic acid, procaine or antibiotics to subdue local inflammation. Such is the balance for the practicing rheumatologist, with many more joint penetrations being for therapy than for diagnosis. Intra-articular therapy – “local therapy for local disease” – remains a popular and attractive concept, with compounds besides corticosteroids and hyaluronic acid [31] in early applications or development: platelet rich plasma [32], mesenchymal stem cells [32], radionucleotides (in some European centers) [33], certain biologics [34], ozone [35], sclerosing agents [36,37], and prolotherapy [38]. More are coming [39]. Proficiency in accurate placement of these compounds is essential to their effectiveness and calls for an experienced hand and possibly even ultrasound guidance. Training in arthrocentesis has not proceeded much beyond the “see one do one” model. Dedicated joint injection clinics, such as the one RWI operated for years, can provide concentrated exposure for trainees. McNabb’s textbook is beautifully illustrated and comes with an interactive eBook with videos [40]. An online guide is available [41] as is a video series specifically focused on the knee [42]. Several videos on YouTube demonstrate techniques of knee arthrocentesis, but these are mostly of poor quality [43], and Karim et al in a recent prospective study found that medical students learn the technique adequately only when video review if followed by feedback from an instructor [44].

Figure 2.

The first description of arthrocentesis. As always, it all goes back to Hippocrates.

Polarizing light microscopy.

Here the hands are on the instrument, not the patient. The trainee approaching the expensive microscope with all necessary components for examining a synovial sample under compensated polarized light may find the whole process daunting. But the principles of the ‘scope are based in the simple optical physics every med student encountered in pre-med physics if not high school [45]. Any conventional microscope can be converted to a compensated polarizing light microscope with two plain polarizing discs plus a glass microscope slide overlaid with two strips of clear cellophane tape [46]. Immediate analysis of synovial fluid from the joint of a patient with a suspected crystalline arthropathy is far superior to relying on the lab, slow to deliver the results and often wrong [47]. Examination of synovial fluid for crystals then determining their birefringence and its angle remains critical to the diagnosis of gout [48] and the arthropathies associated with CPPD [49]. A slide can be preserved for later viewing by sealing the edges of the cover slip with clear nail polish. Skill at crystal identification requires diligence, and online testing may bolster competence [50].

All these bedside skills require little more than well-placed hands and eyes utilizing simple, inexpensive equipment. Senior rheumatologists who absorbed these skills through training and experience are obligated to pass on these skills to the next generation.

Conclusion.

In summary, there are several bedside procedures that make the practice of rheumatology more than just a cerebral exercise at assessing complex diagnoses, devising complicated therapies, and entering data. The chance to actually touch patients and do something has to be a welcome complement to the pure cerebral aspects, and an attraction to the young considering a career in our field. The two older of us have enjoyed long and satisfying careers in rheumatology, with our younger co-author is off to a fun and stimulating start. We all would recommend it to anyone. But there must be a mix. Fortunately, the mix in rheumatology can be a pretty attractive one.