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It is valuable to understand the semantics of consultant comments. A journal article I once read indicated that when a consultant reports having seen a series of individuals with a given problem, it means they have seen two cases. When they report they have experience with a problem, they mean they have seen a (one) case. The expression in my limited experience means they have read about a topic, but have never actually seen a case.
Second opinions are always valuable, but they should be obtained from individual(s) who have actually diagnosed and treated the issue being questioned, and they should have greater experience with the problem than the initial diagnosing individual—whose assessment is being questioned. Rare disorders often require extra-regional consultation, because no one in the region may have more than limited experience with the question.
Guardians of the Standard of Care
Rheumatologists could, perhaps, be considered the guardians of standard of care for those diseases inherent to the specialty. This role is critical, especially related to the assurance of safe utilization of medications characteristic of our armamentarium.
If some rheumatologists deviate from the standard of care, interacting primary care physicians will get the perception that such behavior is so acceptable that they will fail to recognize the quality of care provided by rheumatologists who adhere to the standard of care.
Safe utilization of medications is under attack by what might be considered an insidious force: Some patients really like their convenience and consider that more important than safety. We, as a specialty, have recognized the importance of interval monitoring for the latter. Exemplified by disease-modifying medications (DMARDs), monitoring at one- to three-month intervals has been established and documented to identify adverse reactions at a stage where related progression of damage is likely to be halted and may be reversible. Many patients refuse monitoring at less than six-month intervals and some, even, yearly. Some busy physicians may not be willing to adhere to safe practice principles and simply acquiesce to patient demands. After all, it is time consuming to sufficiently explain the importance of such monitoring to break through preconceived attitudes, and patients often respond that they won’t comply. Some patients state that they accept the need for monitoring and are prescribed a medication, but then they don’t keep the follow-up appointment and demand a prescription renewal without being seen by the physician.
Because we are role models, we promulgate a certain level of care, as exemplified by the completeness of our patient evaluations. If we, as rheumatologists, don’t hold the line, what kind of example are we setting for those healthcare providers not so versed in the disorders for whose treatment we are so dedicated?
Consequences of Deviation
Are there rheumatologists who don’t adhere to minimal standard of care recommendations? Unfortunately, there appear to be, and I believe that to be unacceptable. Patients have suffered irreversible, preventable outcomes when DMARD monitoring has been limited to six-month intervals. Those patients who declined timely appointments (some to save the cost of several physician visits a year) certainly don’t find the toxic results cost effective. When they or their survivors take legal action, the rheumatologist has no defense—because the practice did not meet usual and customary standards.1 If primary care physicians follow that example, does the rheumatologist have shared liability?
If rheumatologists do not stand up to patient demands that compromise safety, what kind of example do we set for primary care physicians with typically quite busy practices? It takes time to change patient perspectives when the patient is fixed in their demand. It takes integrity to deny unreasonable patient demands or to discharge such patients from a practice.
In the words of Benjamin Franklin, “We must all hang together, or assuredly we shall all hang separately.” If some rheumatologists deviate from the standard of care, interacting primary care physicians will get the perception that such behavior is so acceptable that they will fail to recognize the quality of care provided by rheumatologists who adhere to the standard of care.
The frequency of complications (related to failure to adhere to such standards) may lessen primary care physicians’ appreciation of what rheumatologists have to offer and reduce appropriate referrals, to the detriment of all concerned—rheumatologists, primary care physicians and the patients we all serve.
Bruce Rothschild, MD, is professor of medicine at Northeast Ohio Medical University and provides rheumatology services at the Indiana Regional Medical Center. He is a Fellow of the American College of Physicians, the ACR and the Society of Skeletal Radiology and was elected to the International Skeletal Society.
Reference
- Personal communications.
