With increasing shortages of rheumatologists expected in coming years, primary care providers (PCPs) may need to play an important role in the initial diagnosis of rheumatic illness and patient management before or between visits with the rheumatologist. Ideally, the rheumatology community will find more ways to directly provide guidance to these providers; a new ACR resource, Rheumatology for Primary Care, is a step in the right direction.1
A study conducted by the ACR estimates a shortage of approximately 4,100 rheumatology providers by 2030 in the U.S., with disproportionate needs in certain areas of the country.2 In many areas, such shortages are already affecting care; some patients wait many months—sometimes even a year or longer—before they are seen by a rheumatologist.
Beth L. Jonas, MD, FACR, chief of the Division of Rheumatology, Allergy and Immunology at the University of North Carolina at Chapel Hill, is a member of the ACR Workforce Solutions Committee, a group focused on exploring different avenues to ameliorate these workforce challenges and improve patient access. One of these is the creation of virtual training programs and resources.
Dr. Jonas
Primary Care Management of Rheumatology Patients
According to Dr. Jonas, many rheumatologic conditions—such as osteoarthritis, gout or uncomplicated rheumatoid arthritis—can often be managed in a primary care setting.
Thus, the committee created a working group to create the new resource for primary care providers.
“The more our healthcare provider partners in the community really understand about rheumatology, the better off the patients are going to be,” says Dr. Jonas.
David Engelbrecht, MD, a rheumatologist who divides his time between two underserved areas, Northern Light Maine Coast Hospital in Ellsworth, Maine, and a clinic in the Bronx, New York, agrees that many patients referred to him could be managed by primary care providers. But primary care providers may be uncomfortable with such factors as a positive anti-nuclear antibody (ANA), a slightly elevated erythrocyte sedimentation rate or a low positive rheumatoid factor, he explains.
Dr. Engelbrecht
“I understand them not wanting to miss a potentially serious illness,” says Dr. Engelbrecht. “That’s where I think some education can be very helpful in making them feel more comfortable managing these patients.”
Milap Bhatt, DO, a family medicine physician at Erie Family Health Center, a federally qualified health center, and core faculty member at Swedish Hospital, both in Chicago, was part of the Rheumatology for Primary Care Working Group. He provided feedback on the kind of information primary care providers most need at the point of service.
His patients face many barriers, such as difficulties navigating the healthcare system and getting to different appointments, says Dr. Bhatt. Moreover, his patients may not be able to get an appointment with a rheumatologist as urgently as he’d like.
“With all these barriers, if we can handle their care without sending them to a specialist, that’s great,” says Dr. Bhatt.
Although Dr. Bhatt feels confident managing certain aspects of rheumatology diagnosis and care, he has felt less certain about other aspects, such as changing a medication’s dose or a approach after first-line treatment failure. This uncertainty may stem from inexperience in rheumatology or from a lack of available expert mentorship in a particular situation, he notes.
Dr. Bhatt
In general, Dr. Bhatt is comfortable differentiating potential autoimmune etiologies from non-autoimmune ones. However, he notes that certain borderline and equivocal cases can be more challenging to interpret. “Is it appropriate to jump to treatment if some of the lab results are positive but others are not? What if the ANA is just a little bit positive? I think there can be a lot of uncertainty for those of us in primary care.”
For the Rheumatology for Primary Care resource, the authors wanted to provide the key information primary care providers would need at the point of care. Part of the challenge is that primary care providers often face significant time pressures during their appointments, and they may only have a few moments to investigate the best approach. Dr. Bhatt points out that resources from the primary literature can be overwhelming to utilize, and even secondary resources, such as UpToDate, don’t always easily provide the information he needs most quickly, and the applicability to his patient may not be clear.
To address such issues, the new Rheumatology for Primary Care resource includes practical information, for example, about when an ANA test should be ordered, its lack of specificity but high sensitivity, and the importance of looking at titers. The resource provides key clinical information on symptoms, testing, diseases and medications, also utilizing case studies to provide clinical pearls and management considerations. The resource is designed not just to benefit physicians, but also other primary care providers, such as nurse practitioners and physician assistants.
Initial Examination & Patient Hand-Off
Dr. Jonas points out that in addition to helping primary care providers successfully manage certain patients without the need for referral, the resource can help primary care providers identify patients who do need specialist care. Given a thorough and appropriate initial evaluation by a primary care provider, a specialist can assess the patient and deliver care more quickly when they do eventually see the patient.
Another key factor is correctly identifying and triaging the subset of patients with severe disease who can’t wait several months for referral. Dr. Jonas notes that it’s important for primary care providers to successfully identify those patients and clearly communicate that information to rheumatologists (e.g., a protein in the urine for a patient with potential lupus), so those patients can be scheduled quickly for an urgent clinic appointment or even seen via emergency care providers if needed.
Dr. Meyers
Mollie R. Myers, MD, who recently began work as a family medicine doctor at Northern Light Primary Care, Hampden, Maine, notes, “I want to know which people need to be referred, give them a full workup and maybe even start some sort of treatment, but then leave the finer management to [rheumatology] specialists.”
In-Person Mentoring
Some people have characterized overall medical education in rheumatic and musculoskeletal issues as inadequate. This may pose a significant problem because 10–30% of the complaints that drive patients to primary care may be rheumatic or musculoskeletal in nature. Some physicians lack confidence in certain elements of their diagnosis and management, as well as the musculoskeletal exam or arthrocentesis; not all may be able to distinguish autoimmune disease from other causes.3
Physicians trained in family medicine, internal medicine or pediatrics who opt to become primary care physicians vary in the amount of rheumatology-specific training they receive. During medical school and residency, rotations in rheumatology are typically optional. Trainees do receive didactic education in these topics, and they see many patients with musculoskeletal and rheumatic complaints during clinic. However, Dr. Myers points out this is typically done under the preceptorship of non-specialists who lack the expertise of rheumatologists.
Although virtual resources can provide significant support, in-person training and mentoring can provide an additional level of education and confidence in treating rheumatology patients. For example, Dr. Myers chose to pursue a plus-one post-residency program in osteopathic neuromusculoskeletal medicine after completing her initial residency training in family medicine. As part of this plus-one program, she opted for a month-long rotation in rheumatology, in which she spent three weeks with Dr. Engelbrecht and another week with his partner, Charles D. Radis, DO, also a rheumatologist in Ellsworth.
Dr. Myers points out that musculoskeletal complaints directly affect other aspects of health that are core to general practice. “If someone isn’t exercising and walking, their cardiovascular health suffers, as does their mental health. I like working with these issues as much as I can manage on my own, so I don’t have to send everybody out to orthopedics or rheumatology,” she says.
Dr. Myers cited the physical exam as a key area in which the rotation was helpful, for example, in learning how to better differentiate inflammatory arthritis from more mechanical arthritis. “That’s a big factor in knowing if I may need to send them for referral. You can watch as many videos as you want, but that’s different from being there and feeling the joint and getting input from someone with expertise.”
Dr. Myers also notes how helpful it was to get input about the next steps in laboratory evaluation and learning more about how to follow up on labs in situations where she might previously have felt stuck.
“You want to be efficient about it, so you aren’t sending the patient to the lab over and over again,” she says, “but you also want to be cost efficient and not order every single lab every time.”
Dr. Myers particularly enjoyed learning more about the nuances of preventive care in the context of rheumatology patients (e.g., vaccine management).
Dr. Engelbrecht shares his great respect for primary care providers, who must maintain a huge breadth of knowledge to manage their patients, and he saw the experience as a great opportunity for bidirectional learning and exchange, a chance for him to review some internal medicine skills and knowledge. Rheumatologists tend to be more holistic in their care than some specialists, but working directly with primary care doctors gives another layer of insight.
“Primary care doctors are really good at seeing the patient as the whole picture,” notes Dr. Myers, “seeing how the rheumatologic disease fits in with their other comorbidities, the effect it has in the workplace and at home, the impact on their families and communities.”
Ideally, Dr. Engelbrecht would like to see shadowing opportunities for primary care providers beyond residency. Theoretically, group and hospital practices could sponsor their employees to spend time shadowing a rheumatologist to gain more expertise and confidence handling these patients. Although this would require a financial investment, it might eventually pay off, and it could certainly improve care in the long term.
Rheumatologists should engage in informal question-and-answer sessions with primary care providers to build overall knowledge of important aspects of rheumatology, says Dr. Engelbrecht.
To support the rheumatology workforce, Dr. Engelbrecht also notes the importance of establishing more rheumatology fellowships, to which there are often more applicants than available slots, and he urges clinicians later in their careers to consider moving to part-time work, as he has done, instead of retiring.
Dr. Myers urges specialists, including rheumatologists, to take on residents, medical students and other trainees when they have the opportunity. “I think sometimes people might worry that having a learner there, a student or a resident, would slow them down and make them less efficient,” she says. “But I think in the long run that experience will pay off in the future, as you get more appropriate referrals and more thorough workups done in patients by the time you see them.”
Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.
References
- ACR. Rheumatology for primary care. https://rheumforprimarycare.org.
- Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.
- RC Robbins, Maciuba JM, Maggio LA, Samuel A. Continuing professional development in rheumatology for primary care clinicians: A systematic review. Arthritis Care Res (Hoboken). 2023;75(4):734–742.
