Chart a New Course: A Rheumatologist Talks about Practicing in an Orthopedic Environment

Working as a rheumatologist in a rheumatology practice rather than in an orthopedic practice comes with numerous differences, says Sheeja Francis, MD, a rheumatologist who worked at the University of Michigan in Ann Arbor for seven years and, in January 2015, became the first rheumatologist to work at Orthopedics & Sports Medicine PC, in Monroe, N.Y.

Dr. Francis explains: “Because there were not many rheumatologists practicing in our area, primary care physicians were sending patients with autoimmune conditions, such as rheumatoid arthritis [RA] and gout, to orthopedists,” Dr. Francis says. These referrals led the orthopedic practice to explore adding rheumatology services to improve patients’ access to care.

“Since starting at the current practice, I have seen a large number of patients with severe deforming [RA] who were not taking any disease-modifying anti-rheumatic drugs [DMARDs] because they had never seen a rheumatologist to start appropriate therapy.”

Although rheumatology is based heavily on the management of chronic conditions, orthopedics is based more on procedures and subsequent care. An orthopedic clinic evaluation does not require a full set of vital signs. However, these are required in a rheumatology clinic. Given this difference, Dr. Francis needed to purchase devices to measure vital signs, such as a blood pressure cuff, thermometer and scale, when she moved to the orthopedic practice.

Protocols for in-clinic procedures also differ. “Although rheumatologists and orthopedists perform joint and soft tissue injections, our protocols are often very different in terms of approach, as well as the medications used,” she says. “This difference is likely because our training is very different.”

According to Dr. Francis, “Although both specialties treat patients with bone and joint pain, rheumatologists focus more on the systemic causes of these issues, [whereas] orthopedists focus on particular areas of the body, such as specific joints and the spine.”

Dr. Francis also says, “The regulations and reporting differ in rheumatology [from] orthopedic practices.” The focus on documentation varies.

Overcoming Challenges
As the first rheumatologist to join Orthopedics & Sports Medicine PC, Dr. Francis’ initial challenge was finding ancillary staff members who could focus on the needs of rheumatology patients.

“Medical assistants for orthopedists are trained to obtain a patient’s history in a certain way, with a focus on date of injury and previous procedures. In contrast, medical assistants working in rheumatology are trained to obtain a thorough systemic history during the initial patient intake,” she says. “It took a while to train the medical assistants and nurse to focus on the needs of rheumatology.”

Dr. Francis also faced administrative challenges, such as with MACRA reporting. “MACRA reporting has been significantly delayed because our electronic health record (EHR) system is not yet compatible with the current reporting needs,” she says. “As the practice is evolving to recognize the expanding future needs for reporting to various clinical registries, we are at the threshold of acquiring a new EHR system that will make the process much more efficient.”

Combining Silos Makes Sense
Alfonso E. Bello, MD, MHS, FACP, FACR, DABPM, a clinical associate professor of medicine at the University of Illinois College of Medicine at Chicago and director of rheumatology research at Illinois Bone & Joint Institute LLC, has found that having rheumatologists and orthopedists in the same practice works well, because patients with musculoskeletal disorders often see an orthopedic surgeon first, even though they may not need a surgical procedure.

“Many times, patients are seen by orthopedic surgeons as their first musculoskeletal specialist when, in fact, they may be better served by a rheumatologist,” he says. “My orthopedic partners are well equipped to identify patients with rheumatologic disorders and facilitate transfer of care to me—thereby accelerating proper care.”

This arrangement also makes sense because rheumatologists often use or prescribe the same ancillary aspects as orthopedists, such as magnetic resonance imaging and physical therapy. What’s more, Dr. Bello finds it beneficial to communicate directly with the surgeons who he refers patients to, and vice versa.

Dr. Bello, who used to work at a multi-specialty practice, notes that in some instances patients need to see both a rheumatologist and an orthopedist. “[Because we’re] both under the same roof, we can provide convenient and well-rounded comprehensive care. I think the wave of the future will be to combine these two silos.”

Karen Appold is a medical writer in Pennsylvania.