~~Official Rheum Gathering thread~~

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Crayola227

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the psych forum is debating whether or not fibromyalgia is real,

and I thought it would be great to get some input from rheum

rheum, unlike some other IM subspecialties, doesn't seem to have its own forum on this board

so I don't know where my rheum dawgs are at

chime in if you are rheum, rheum adjacent, or just particularly knowledgeable about rheum, especially the more "controversial" rheum issues going around these days

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the psych forum is debating whether or not fibromyalgia is real,

and I thought it would be great to get some input from rheum

rheum, unlike some other IM subspecialties, doesn't seem to have its own forum on this board

so I don't know where my rheum dawgs are at

chime in if you are rheum, rheum adjacent, or just particularly knowledgeable about rheum, especially the more "controversial" rheum issues going around these days

Real or not, it is not an inflammatory or autoimmune disease (even though some people are pushing with religious conviction to make that case) and there is no good reason to believe that these people are in good hands when followed by rheumatologists. IMHO, it is a patient population that would be much better off in the hands of a skilled psychiatrist than a rheumatologist who tries to either get rid off them or have them all seen in the fellows clinic.
 
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I am just a MS3 but interested in rheumatology. I see that rheumatology has taken fibromyalgia under its rubric and provided guidance in its diagnosis and treatment. In Canada the prevailing view seems to be that it should be managed by primary care and rheumatologist only involved for consultations.
The idea of any opioids for this type of illness seems really counterintuitive.


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How early into PGY-1 should I get started on making myself attractive for a good rheum program?
 
Also, what is the job market like right now for Rheum compared to other IM specialties?
 
How early into PGY-1 should I get started on making myself attractive for a good rheum program?
Just focus on being a good intern for the first 6 months and then you can find a mentor and start doing research projects in the second half of intern year. That should give you ample time over the course of the next 1.5 years to make yourself "attractive" on paper. Don't spread yourself too thin early on in residency though. Your primary goal should be in becoming the best medicine resident you can early on.
 
The debate over whether fibromyalgia is "real" or not is idiotic. Anyone who has seen more than a handful of fibromyalgia patients can tell you that it is "real"--the complaints and symptoms are highly stereotyped and conserved across patients. There is a real phenomenon occurring. What people generally mean when asking is fibromyalgia "real" or not is whether it has a basis in inflammatory or autoimmune pathology, and all available evidence suggests that it does not. Most current hypotheses about the nature of fibromyalgia and other chronic pain syndromes has to do with the concept of "central pain sensitization", which I would encourage anyone to read about if they are interested in the topic. The bottom line is that fibromyalgia is most likely a functional neurologic disorder with a heavy psychiatric overlay.

As to the question of how involved rheumatologists ought to be in managing FM, it's going to depend quite a bit on your practice setting and community. I end up seeing and managing quite a bit of FM primarily because the primary care folks here are overworked and not very thoughtful. FM can easily be managed by a competent primary care doctor, if you can find one. The role of subspecialists to my mind is primarily to rule out alternative, more serious pathology. An article this month in Arthritis Care & Research implies that 10-20% of patients labelled as "fibromyalgia" meet ASAS criteria for axial spondyloarthritis. If identified early and treated appropriately, significant improvement is possible in those patients, as compared with fibromyalgia in which very little improvement tends to occur in my experience.

Otherwise, there is nothing magic about treating FM. Some combination of anticonvulsant pain meds (gabapentin, pregabalin), SNRIs (duloxetine, venlafaxine, milnacipran), muscle relaxants (primarily cyclobenzaprine), TCAs, and NSAIDs is generally used. Opioids are conclusively harmful in fibromyalgia and should not be used, period. That said, every FM patient referred to me is already on 40-60mg morphine equivalents per day from their PCP (and guess what... their pain score is still 9.8/10). Regular low impact physical exercise, maintaining a healthy body weight, and practicing good sleep hygiene are the most demonstrably effective interventions in FM, but anyone with any real-world clinical experience can tell you how receptive patients are to those recommendations (not very). Like I said, this is all stuff a PCP could do--they just either can't or choose not to. Some rheumatologists I know see FM patients once, tell them the deal, and don't follow up. That may be fine in big cities or academics, but in smaller communities you get stuck managing it to some extent if for no other reason than not wanting to alienate your colleagues and referral base.
 
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The debate over whether fibromyalgia is "real" or not is idiotic. Anyone who has seen more than a handful of fibromyalgia patients can tell you that it is "real"--the complaints and symptoms are highly stereotyped and conserved across patients. There is a real phenomenon occurring. What people generally mean when asking is fibromyalgia "real" or not is whether it has a basis in inflammatory or autoimmune pathology, and all available evidence suggests that it does not. Most current hypotheses about the nature of fibromyalgia and other chronic pain syndromes has to do with the concept of "central pain sensitization", which I would encourage anyone to read about if they are interested in the topic. The bottom line is that fibromyalgia is most likely a functional neurologic disorder with a heavy psychiatric overlay.

As to the question of how involved rheumatologists ought to be in managing FM, it's going to depend quite a bit on your practice setting and community. I end up seeing and managing quite a bit of FM primarily because the primary care folks here are overworked and not very thoughtful. FM can easily be managed by a competent primary care doctor, if you can find one. The role of subspecialists to my mind is primarily to rule out alternative, more serious pathology. An article this month in Arthritis Care & Research implies that 10-20% of patients labelled as "fibromyalgia" meet ASAS criteria for axial spondyloarthritis. If identified early and treated appropriately, significant improvement is possible in those patients, as compared with fibromyalgia in which very little improvement tends to occur in my experience.

Otherwise, there is nothing magic about treating FM. Some combination of anticonvulsant pain meds (gabapentin, pregabalin), SNRIs (duloxetine, venlafaxine, milnacipran), muscle relaxants (primarily cyclobenzaprine), TCAs, and NSAIDs is generally used. Opioids are conclusively harmful in fibromyalgia and should not be used, period. That said, every FM patient referred to me is already on 40-60mg morphine equivalents per day from their PCP (and guess what... their pain score is still 9.8/10). Regular low impact physical exercise, maintaining a healthy body weight, and practicing good sleep hygiene are the most demonstrably effective interventions in FM, but anyone with any real-world clinical experience can tell you how receptive patients are to those recommendations (not very). Like I said, this is all stuff a PCP could do--they just either can't or choose not to. Some rheumatologists I know see FM patients once, tell them the deal, and don't follow up. That may be fine in big cities or academics, but in smaller communities you get stuck managing it to some extent if for no other reason than not wanting to alienate your colleagues and referral base.

Anecdotally, I have seen good results with Gabapentin. For one particular patient the difference was astronomical.

I shy away from prescribing narcotics for FM and rheumatological conditions. The emphasis should be on controlling the disease process whenever possible.
 
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Anecdotally, I have seen good results with Gabapentin. For one particular patient the difference was astronomical.

I shy away from prescribing narcotics for FM and rheumatological conditions. The emphasis should be on controlling the disease process whenever possible.

Anecdotal is definitely the operative word there... I probably write 15-20 gabapentin scripts every week and the results for FM specifically are mixed at best. But as you say, every now and then someone will have a dramatic improvement. Most of the time though, if they acknowledge a benefit at all, the VAS pain score goes from 10 to 9.6 :laugh:

EDIT: it occurs to me that if you are not a rheumatologist or pain management specialist you are also probably not seeing the same FM population that I am. We tend to only get the malignant fibro :bang:

And yes, as I mentioned above, except in very limited circumstances, opioids are more or less contraindicated in chronic pain syndromes like FM. To just pick a representative citation off the first page of a PubMed search, you can find this statement:
There are no randomized clinical trials of opioids in FM, but large population-based surveys and results from tertiary pain clinics have shown no evidence that long-term opioid treatment is effective for FM. Indeed, long-term opioid use in FM has been associated with poorer outcomes than in individuals who are not receiving opioids. Furthermore, mechanisms of altered pain processing in FM are not likely to be improved with opioids. In fact, the aggregate studies suggest that the endogenous opioid system may contribute to the hyperalgesia seen in FM, akin to OIH.

Clawu DJ et al. Opioid use in fibromyalgia. Mayo Clin Proceedings. 2016;91:640-8. http://www.mayoclinicproceedings.org/article/S0025-6196(16)00102-6/pdf
 
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In a rheumatology practice what percentage of your patients are FM? Is it mostly consults or day to day management? Are you able to limit it to just consults without irritating your referral base?


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All depends on your situation. If you're in an academic referral practice you will see very little fibromyalgia. If you're in community based private practice you will see a lot of it. PCPs seem to love nothing more than checking ANAs in FM patients every 3 months until they get one 1:40, then tell the patient they definitely have lupus and ship them to a rheumatologist. You will never again convince those patients they don't have lupus

How much you accept/manage depends on lots of factors. I didn't say no to any referrals until I was booked 2 months out (although I would prioritize obvious inflammatory disease over the FM patients due to treatment urgency). Now that I stay booked out at least 6 weeks I will say no to referrals that don't at least have an abnormal lab result or documented abnormal physical exam. You'd be amazed/horrified how many referrals I get for "labs normal, exam normal, patient still hurts and requests rheum referral"


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All depends on your situation. If you're in an academic referral practice you will see very little fibromyalgia. If you're in community based private practice you will see a lot of it. PCPs seem to love nothing more than checking ANAs in FM patients every 3 months until they get one 1:40, then tell the patient they definitely have lupus and ship them to a rheumatologist. You will never again convince those patients they don't have lupus

How much you accept/manage depends on lots of factors. I didn't say no to any referrals until I was booked 2 months out (although I would prioritize obvious inflammatory disease over the FM patients due to treatment urgency). Now that I stay booked out at least 6 weeks I will say no to referrals that don't at least have an abnormal lab result or documented abnormal physical exam. You'd be amazed/horrified how many referrals I get for "labs normal, exam normal, patient still hurts and requests rheum referral"


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My dislike for chronic pain is one of the primary reasons I didn't do primary care. In an academic setting I never consulted Rheum unless I had some kind of weirdly positive serologies with a suspicion of a real rheumatological disorder, but I can see where in private practice that could be tempting.
 
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All depends on your situation. If you're in an academic referral practice you will see very little fibromyalgia. If you're in community based private practice you will see a lot of it. PCPs seem to love nothing more than checking ANAs in FM patients every 3 months until they get one 1:40, then tell the patient they definitely have lupus and ship them to a rheumatologist. You will never again convince those patients they don't have lupus

How much you accept/manage depends on lots of factors. I didn't say no to any referrals until I was booked 2 months out (although I would prioritize obvious inflammatory disease over the FM patients due to treatment urgency). Now that I stay booked out at least 6 weeks I will say no to referrals that don't at least have an abnormal lab result or documented abnormal physical exam. You'd be amazed/horrified how many referrals I get for "labs normal, exam normal, patient still hurts and requests rheum referral"


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drfunktacular, what are some of the biggest differences you noticed between residency and dealing with common IM stuff on the wards, and transitioning to fellowship? Given that a lot of rheum is outpatient in clinical practice, but much more inpatient during training, how much variety of pathology did you get to see during fellowship compared to what you see during your attending practice. What you think the ability of midlevels is to encroach into Rheum practice? Did you see any practices where there were many physician extenders in rheum on your job searching?
 
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PCPs seem to love nothing more than checking ANAs in FM patients every 3 months until they get one 1:40, then tell the patient they definitely have lupus and ship them to a rheumatologist.

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Lol that's a great idea. I will implement it in my practice and refer those patients to my wife (she is a rheumatologist) :hilarious:
 
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Any ideas about the rheum boards results release date? TIA
 
Who are you talking to? necrobump for the wrong thread? No patients here are asking for medical advice

Lol, the statement about no medical advice on SDN can't be said enough, especially in threads about some topics. Don't worry about it. The thread is on track!

We have been discussing a topic that has also appeared in a different subforum, I link it here if it is of interest:

Is Fibromyalgia a real syndrome, or a new label for hypochondria?

Not terribly on track, but I think is interesting medicine to share nonetheless, about functional movement disorders. Just, the concept that patients can have dysfunction/pain where all systems appear "normal," but there is a physical basis to their suffering and it is not under conscious control. Of course, whether you have cancer or depression, the mind is powerful and good lifestyle inputs can always improve subjective experience.

this aspect of brain science is trippy cool. If you were to ever read one of my posts rather than just skip it......

Functional movement disorders

Many terms have been debated to describe “psychogenic” movement disorders. A thoughtful discussion was published in the The Lancet Neurology in 2012 by Edwards, et al. The 2002 study referenced there by Stone et al., suggests that overall patients find the term “functional” more acceptable and with less negative connotations.

This is important, because functional movement disorders have been considered to be related to psychological trauma, however epidemiologic studies do not support this (Stone 2011) (Kranick 2011). Even if they were, this would not explain what may be most striking about these conditions. Functional movement disorders are neurologically voluntary movement, but according to patients they have a decidedly involuntary feel to them.

Voluntary movement and that of functional disorders of myoclonus and tremor, involve the premotor cortex, supplementary motor area and motor cortex, which are used in motor planning and execution. When it comes to patting your head and rubbing your belly at the same time, one voluntary motor plan can interfere with another, and this is seen with movement from a functional disorder.

However, there is more to voluntary movement than execution. Research into the pathophysiology of functional movement disorders is looking into the perception of movement, and not just the mechanisms that generate it.

Imaging of patients while they are experiencing functional tremor was compared to imaging while these same patients were voluntarily imitating their tremor – meaning that the abnormal movement was being compared with decidedly normal voluntary movement in the same brain. During the abnormal movement there was hypoactivation of the temporoparietal junction, an area suspected to compare predicted and actual sensory feedback. This may give the sense the movement was involuntary. (Edward 2012).

It is theorized there is a feed-forward signal from the frontal lobes that includes the premotor and motor cortices, but also goes to the parietal lobe so planned movement can be compared to actual movement to allow for motor correction. This may also be the way a person experiences the sense of telling their body to move and receiving feedback that it did. (Edward 2012).

A neurosurgical study used electric impulses to stimulate the parietal area, and showed that low intensities gave the sense that patient wanted to move a certain part of their body, and high intensities made patients feel like they actually had moved when they hadn’t. Stimulation of the premotor region caused movement without any awareness of it. This suggests that the parietal area is responsible not only for the sense of wanting to move your body, but also with the sense that you actually did, and this may be the reason that you believe you were the one to do so. This may support the feed-forward signal theory. (Desmurget 2009).

What is presented here explores the pathophysiology of only one aspect of functional movement disorders – the sense of being involuntary. These disorders may not have hard anatomic structural abnormalities like that found in Parkinson’s, but the suffering is just as involuntary. Greater understanding of functional movement disorders may not only yield future therapies and help strengthen the therapeutic alliance, it may also help us to understand and treat other movement disorders.

References:
J Stone, W Wojcik, D Durrance et al. What should we say to patients with symptoms unexplained by disease? The “number needed to offend”. BMJ, 325 (2002), pp. 1449–1450.

Stone, J. and Edwards, M. J. How “psychogenic” are psychogenic movement disorders?. Mov. Disord., (2011), 26: 1787–1788.

Kranick, S., Ekanayake, V., Martinez, V., Ameli, R., Hallett, M. and Voon, V. Psychopathology and psychogenic movement disorders. Mov. Disord., (2011), 26: 1844–1850

Mark J Edwards, PhDa, Prof Kailash P Bhatia, MDa. Functional (psychogenic) movement disorders: merging mind and brain. The Lancet Neurology. Volume 11, Issue 3, March 2012, Pages 250–260

Desmurget M, Reilly KT, Richard N, Szathmari A, Mottolese C, Sirigu A. Movement intention after parietal cortex stimulation in humans. Science. 2009 May 8;324(5928):811-3.

I shared this despite it being related to movement disorders. I believe there are points that are pertinent.

1) The use of the term "functional" neurologic disorder vs "psychogenic." I referenced a great paper on why I think this matters. Different implications.
2) The idea of some of these "psychogenic" (but really functional neurologic) disorders being associated with psychological trauma, has not been borne out by epidemiology. There is a citation.
3) No one believed people with "disorders of voluntary movement" because it quite literally is a disease of perception. We know when they walk in the room that all the neuromuscular systems for voluntary motor planning, execution, and feedback, are intact. While experiencing their disorder, still, all the parts that are involved in movement are engaged and functioning normally, for the most part. On imaging, shaking your hand on purpose, and when you thought it wasn't your idea from your "psychogenic" tremor, it all looks the same - except there is some part of your brain, decidedly not under conscious control, not working right. Furthermore, the evidence shows this part of your brain is responsible for perceiving movement as your idea.

The perception is off!

What it has in common, I believe, with what I think are likely other functional neurological disorders - is that there is altered perception, that this is based in the brain.

But not the way we've discussed in the thread. Having a basis in the brain, let's not conflate functional or central mechanisms of such diseases with typical psychiatric or neurologic insults or dysfunctions, or that they may be more or less amenable to such interventions. Not all brain function is at the level of the synapse, for example. The guy who has a hard time walking after a cerebellar stroke - you don't suggest Prozac and talk therapy for that symptom, do you?

Give the FM people with the pressure point patterns a break, not opiates, that's all I'm saying. It might not be as simple as fixing their social stressors and coping skills.

This can get even more bizarre for you - explore the work by Mark J. Edwards, whoever he cites. Very good respectable work.

Based on this work, that there is a different circuit for executing the movement, and a different circuit for perceiving the desire for initiation of movement, they found it appeared the part of the brain that actually causes the movement - the motor cortex - actually FIRES FIRST. The part of your brain that thinks to itself "move my hand to hit a button in this researcher's experiment on fMRI" - receives this information and processes, and appears to fire AFTER the fact.

To make this clear, your brain starts moving your body in voluntary ways - to pick up an object - BEFORE the part of your brain that perceives this as YOUR idea, goes off.

These guys are doctors. They aren't trying to get into metaphysics here, just do some fMRI. Still, all of their work freaked me out.

It also matches up with some other work that suggests that the "ego" and "free will" as we know it may be convenient adaptations with evolutionary advantages.

YOU as you know it, are simply your body's version of the Matrix. Your cat got what it got, you got programming to make you sentient and think about "me." Your body, including brain, just does stuff, part of which is putting on the elaborate illusion that is you, and making "you" think it's responsible for getting off the couch and baking a pizza. Somehow, the decision to stand up, this was made by your brain in a loop, that you were then let in on after the fact. Creepy.

One way or the other, it's coming from "me," it's fine. I already know I'm ran by all sorts of unconscious processes - apparently having the idea to get off my couch is one of them.

TLDR:
Just, maybe we're more the puppets of our bodies than we give ourselves credit for. Maybe we think "we" are in more control than we are.
That doesn't mean responsibility is absolved, I just tend to take it easy on people for their feelz.
 
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Back to more focussed rheum related topics,

I found this - from the ACR, an initiative of the ABIM - List of Top 5 Things for Choosing Wisely - some EBM for being more cost-conscious

http://www.rheumatology.org/Portals/0/Files/The List_Adult Rheumatology.pdf


Also, the ACR guidelines for a host of awesome rheumatic conditions!

Those panel to order/interpret can be a bitch to memorize, so yay reference!

http://www.rheumatology.org/Practice-Quality/Clinical-Support/Criteria/ACR-Endorsed-Criteria
 
Also, the 2010 excerpt and full article on the Fibromyalgia Diagnostic Criteria. This replaced the 1990 guidelines.

Excerpt
http://www.rheumatology.org/Portals/0/Files/2010 Fibromyalgia Diagnostic Criteria_Excerpt.pdf

Full
http://www.rheumatology.org/Portals/0/Files/2010_Preliminary_Diagnostic_Criteria.pdf

I'm suspicious about these changes, and will discuss in a follow up post.


We don't get a lot rheumatologists in here besides the amazing drfunktacular, but we can also ask career and other questions and hope for some advising.
 
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