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First year of a rheumatologist in private practice.

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LETTERS
718
First year of a rheumatologist in private
practice
Figure 2. Giant cell arteritis. Inflammatory infiltrate of the wall that
contains multinucleated giant cells ( x 100).
on the possibility that alterations of the immune system have a role in the pathogenesis of this disease (6).
Because the disorders that have been reported in
association with PMWGCA involve the immune system, we think that a similar mechanism might have
favored the development of giant cell arteritis in our
patient.
FRANCISCO
PEREZ-JIMENEZ,
MD
Department of Medicine
FERNANDO
LOPEZ-RUBIO,
MD
Department of Pathology
FRANCISCO
CARADILLAS,
MD
JUANJIMENEZ-ALONSO
JOSEJIMENEZ-PEREPEREZ,
MD
Department of Medicine
Ciudad Sanitaria de la Seguridad
Social Reina Sofia
University of Cordoba Medical School
Cordoba, Spain
1. Wilske KR, Healey LA: Polymyalgia rheumatica: a manifestation of systemic giant-cell arteritis. Ann Intern Med
66:77-86, 1967
2. Siege1 RC: Scleroderma. Med Clin North Am 61:283-297,
1977
3. Roe RL: Drug therapy in rheumatic diseases. Med Clin
North Am 61:405-418, 1977
4. McKenzie AH: The polymyalgia rheumatica syndrome.
Geriatrics 24:158-166, 1969
5. Huskisson EC, Dieppe PA, Balme HW: Complicated
polymyalgia. Br Med J 2:1459, 1977
6. Ettlinger RE, Hunder GG, Ward LE: Polymyalgia rheumatica and giant cell arteritis. Ann Rev Med 29:15-22,
1978
To the Editor:
Having just completed my first year of private
practice in rheumatology, I read with interest the
report by Bohan of his experience in Newport Beach,
California (Bohan A: The private practice of rheumatology: the first 100 patients. Arthritis Rheum 24: 13041307, 1981). The fact that nearly 75% of his patients
had inflammatory and connective tissue disorders contrasts with my experience.
I was the first and only board-certified rheumatologist at a 442-bed urban general medical-surgical
hospital in Cleveland, Ohio. My office was adjacent to
the hospital, and my practice was purely consultative
rheumatology . The diagnoses for my first 150 patients
are listed in Table 1. Clearly, my experience differed
considerably from that of Bohan. Approximately 45%
of all the patients had noninflammatory conditions
(degenerative joint disease, fibrositis, back syndrome,
muscle strain). Patients with these conditions made up
only 27.5% of Bohan’s practice. The major reason for
this difference is most likely the incidence of rheumatoid arthritis and fibrositis (myofascial pain syndrome)
in the 2 groups of patients. The incidence of fibrositis
was much greater in my practice (16% versus 4.7%)
and rheumatoid arthritis much lower (7% versus
31.1%).
A study of my referral sources revealed closer
agreement with Bohan’s data. The top four categories
were identical to his: internists, 18%; general practitioners, 18%; orthopedists, 17%; and self-referred,
16%.
Table 1. Diagnosis in 150 consecutive patients
Diagnosis
Degenerative joint disease
Fibrositis
Bursitidtendinitis
Uncertain
Rheumatoid arthritis
Back syndrome
Gout
Neuropath y
Muscle/ligament strain
Systemic lupus erythematosus
Muscular chest pain
Carpal tunnel syndrome
Osteoporosis
Spondylitis, juvenile rheumatoid arthritis,
psoriatic arthritis, reflex dystrophy,
Paget’s disease, Raynaud’s syndrome,
scleroderma, adult Still’s disease,
polymyalgia rheumatica
%
19
16
11
9
I
6
5
5
5
2
2
1
1
0.6
LETTERS
719
There are several potential explanations for the
differences in the 2 patient groups. A private practitioner of rheumatology in Cleveland is competing with
several medical centers in the same city for patients. A
substantial number of patients with connective tissue
diseases may be referred preferentially to these centers by referring physicians. The patient population
served by the urban hospital to which my practice was
attached is probably different from that in a communit y such as Newport Beach. Finally, although referrals
were similar, there were some differences in referral
sources. For example, there were more orthopedic
(17% versus 9.5%) and self-referred (16% versus 9.5%)
patients in my practice. This certainly could have an
impact on the nature of problems seen.
The nature of rheumatology private practice is
variable. Studies such as Bohan’s are needed for
planning rheumatology training programs and assessing manpower needs. As Dr. Bohan has observed and
my experience confirms, however, it is dificult to
generalize from one rheumatologist’s experience. A
rheumatologist-in-training should assess each potential practice situation carefully.
BOOK REVIEWS
attending physician who just cannot remember all the
appropriate references. What matters is the insight
into clinical rheumatology that the book offers to the
novice, and there it succeeds. Try it as an introductory
work for your new students or residents the first day
they appear on your service.
Tutorials in Clinical Rheumatology. Douglas N . Golding, M A , MD, FRCPI. London, Pitman Medical,
1981. 133 pages. Illustrated. $13.50.
This short book may be of interest to medical
students and others just becoming initiated in the art
and science of rheumatology. It features a problemoriented approach to the common and uncommon
diagnostic entities, but coverage of the connective
tissue disorders is scant (one patient has systemic
lupus erythematosus, one progressive systemic sclerosis, and that is the total of illustrative cases for this
category of disease). Reading this book makes one feel
as if one is on ward rounds with a good clinician. He
drops pearls. He reaches into the recent past, when
rheumatology was all history and physical examination with no laboratory support, and remembers how
he made diagnoses then. He adds contemporary concepts and refers to the latest laboratory measures
when such elaboration is appropriate. On rounds, one
can confirm some historic details and check a physical
examination; one can examine the chart for materials
that are in it but only to suggest further tests that might
be done. The book takes this approach. It should
convert some of the undecided to enter rheumatology ,
since it demonstrates the large gaps in our knowledge
that cry for someone to answer. Clinical details are not
yet completely described or understood, so one need
not be a basic scientist to be attracted to this subspeciality. The bibliography is inadequate, but again,
that makes it seem as if one is on rounds with the
DANIEL
J. MAZANEC,
MD
Department of Rheumatic
and Immunologic Diseuse
Cleveland Clinic Foundation
Cleveland. Ohio
E. EHRLICH,
MD
GEORGE
Department of Medicine
Division of Rheiimatology
The Huhnemann Medical College
and Hospital
Philadelphia, P A
Surgical Treatment of Rheumatoid Arthritis. Norbet
Gschwend. Philadelphia, W . B. Saunders Co., 1980,
310 pages. Illnstruted. $60.00.
Surgery in Rheumatoid Arthritis: An up-to-date account. I . F. Goldie. Basel, Switzerland, S. Karger,
AG, 1981. 213 pages. Illustrated. $66.00.
These two books, both originating from Switzerland, have similar titles, are almost identical in size,
price, and subject matter, but are strikingly different in
content.
Dr. Gschwend’s book, written almost solely by
himself, is an English translation with little modification of the German edition published in 1977. In
contrast, the book edited by Dr. Goldie is a series of
isolated topics, written by various authors, mostly
European, but including several Americans. The dif-
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