Does true patient-centered care support self-diagnosis and treatment? How did evidence-based guidelines kidnap and hold hostage true patient-centered, personalized care? What patients say and believe are of equal importance to patient-centered care as their genetic make-up is to personalized care. Care cannot be recommended based on a population average. How are we going reestablish ourselves with our patient as the first and last arbiter of patient-centered, personalized care decisions?
Just before lunch, I see Sue, who has been my patient since she transitioned from the pediatric clinic, 35 years ago. She lost function in her right shoulder and arm strength several weeks ago—greater than can be explained by her ultrasound-proven, completely torn rotator cuff. An MRI of her previously fused neck is planned for this afternoon. As we say our final, emotion-laced goodbyes, she utters those words that have terrorized many physicians, “By the way, one more thing.” She shows me forearm lesions—two red, nodular areas about each about 3×1″, one medially and the other laterally. A no-charge, ‘part of my exam’ ultrasound, showed only swollen fat tissue and normal muscle. My semi-retired brain draws a blank, so I use one of my shout-outs to interrupt my esteemed partner, Julie Carkin, MD.
Armed with her subconscious awareness that history is 90% of the diagnosis, Julie carefully examines Sue and then comes to the question, “Sue, have you been trimming roses recently?” Sue hesitates and then confirms the likelihood that is my first case of sporotrichosis.
Will the future system revalue the diagnostic utility of her astute history and exam that prevented an MRI? How will the system break the trend of increasing physician dissatisfaction in order to attract and support the best docs and staff who are willing to Choose Wisely, by listening to and looking at patients, rather than perform procedures and diagnostics?
During lunch, I take a picture with my necktie-wearing staff, who acknowledge my daily uniform of Snoopy, smiley face, Road Runner and Mickey Mouse ties. I am interrupted by a phone call from a pain doc at the university, who acknowledges my retirement letter and thanks me. She appreciates our integrated-care approach (dietician and counselor on staff) and my focus on recurrent inflammation in many of her chronic pain patients.
Will rheumatology contribute its full potential in solving our chronic pain epidemic? What are the unique or valued contributions we can make?
After lunch, I see 22-year-old Grant and his parents for the first follow-up visit to summarize a transition plan. Although closed to new patients for some time, I had seen him as a favor to a friend. Grant’s chronic fatigue of five years started with a very stressful freshman year in college. Although recent tests from a non-accredited laboratory raised his parents’ hope of a chronic Lyme diagnosis, I focus on his recurring GI symptoms, mild abdominal tenderness and recently elevated CRP. I discuss how the gut and the immune system are interrelated, the work our dietician has done with food sensitivities, small intestinal bacterial overgrowth and the paper about serotonin modulation of the immune system.1 I tell Grant how hard small intestinal inflammatory illnesses are to diagnose, but that medication trials might be of diagnostic/therapeutic utility. I also explain how the combined effects of low-dose antidepressant medications, quality sleep and self-care activities will be important to balancing his immune system. He brightens as I make clear this is not “just in your head” and feels hopeful as I lay out a plan.
