Dr. Firestein agrees. “The primary care doctors have to be trained to know exactly what to look for,” he says. According to Dr. Paget, “because medical school and house staff training in the recognition, diagnosis, and treatment of such disorders is so poor, is it a surprise that well-intentioned physicians on the front line either miss or mistreat these diagnoses or patients altogether because they don’t even know what they don’t know?”
“It’s, in many ways, a grassroots effort with medical schools,” Dr. Paget says, urging rheumatologists to get involved. “The schools have ‘x’ amount of time and resources to do a huge amount of education. They basically cram it in. As a result, a specialty like rheumatology suffers.”
Dr. Cush, who runs an EAC and frequently lectures, says that, while education is certainly needed, most PCPs want to know who and when to refer. Therefore, with his PCPs, he promotes the “Referral Rules” advocated by Paul Emery, MD, professor of rheumatology at the University of Leeds, U.K., that require six weeks of joint symptoms and one of the following symptoms: three or more swollen joints a positive metacarpophalangeal (MCP) or metatarsophalangeal (MTP) squeeze test, morning stiffness for more than 45 minutes, or abnormal labs (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], rheumatoid factor [RF], or classical complement pathway [CCP]).
Dr. Cush believes that “the guy in the trenches, the primary care internist or physician, has no intention of going to a lecture designed to educate them on early RA. They’ve got too many things to deal with already. Thus, we have to create rules that can facilitate patient referral.” To get the word out about the rules, Dr. Cush suggests a $5–10-million national advertising campaign aimed at both PCPs and the general public. He suggests it might be funded by stakeholders (e.g., pharmaceutical companies, foundations, societies, etc.).
“My idea is to make Tuesday ‘Early Arthritis Day,’ ” he says. “Your rheumatologist will see patients every Tuesday and all the PCP needs to do is fill out a prescription pad for the walk-in visit.”
A new initiative is starting at Dr. Cush’s EAC. He is working with the hospital’s public relations department to reach all local primary care doctors in the community, providing referral rules and indicating that nine doctors in the EAC will see patients within two weeks of referral. In Birmingham, Dr. Moreland’s EAC was established by sending out letters to all PCPs in Alabama, saying that his group will try to see all patients in a timely manner. In smaller communities, such as Santa Barbara, Calif., it’s easier for a dedicated rheumatologist to spread the message to area primary care physicians. Timothy Spiegel, MD, MPH, a rheumatologist in Santa Barbara, Calif., who has been in private practice for the past 20 years, knows all the local PCPs and says he has trained many of them to recognize early RA. He makes sure to see referred patients within a week.
