In the mid-eighties I was a fourth year med student and took rheumatology as an elective. At the time, I had no clue about the field and took it at the recommendation of my brother. This was odd in itself as my brother, who has since become an intensivist, has never since shown even the slightest residual interest. I was initially underwhelmed, seeing numerous burned-out rheumatoids as pre-op courtesy consults and acute osteoporotic fractures with an attending who seemed to long for his lab. In the second week my attending and my luck changed as I rounded with the chief of the department. He was an imposing figure, six foot four or more and rather austere, but I soon discovered that though he had an active lab and admininstrative duties, his curiosity for clinical medicine had never been expunged. No case, even the most mundane at first glance, seemed to go past without some comment. Not for teaching purposes, not to look clever, but simply because the world was still full of mysteries, large and small. Even today, whenever I palpate a small tender peri-lumbar lipoma I remember our discussion about fibrositic nodules and whether they in fact existed. I still wonder, as he did, why shoulder bursitis hurts so much at night.
At our first service rounds I remember that a junior staff presented a case of pulmonary sarcoidosis that was on the floor. I don't recall the details, but it included pulmonary and neurological symptoms. After the case presentation there was a review of the latest literature which showed, at that time, that there was no value in giving corticosteroids. After a lively round table discussion which thoroughly impressed me, all seemed to agree, and they then asked the junior attending what he was doing for the patient. To my surprise, he answered with- prednisone! The chief, with everybody uncomfortably silent, asked how he decided upon that course, given the just-discussed literature. He responded with "well, what'ya gonna do". That seemed to satisfy everybody present and we moved along to the next case.
That one service rounds said a lot about rheumatology. Odd, debilitating diseases with mysterious origins and uncertain treatments. Intelligent clinicians sometimes forced into seat-of-the-pants treatments. A world of mysteries, large and small.
As a last note, the junior staff just mentioned has been exonerated, of course. In the may 2007 issue of the American Journal of Medicine, a review of the treatment of sarcoidosis lists corticosteroids as the preferred medication for all manifestations except arthritis and E. Nodosum, where they were second to nsaids.