The Character of Rheumatology Has Changed Over the Past 50 Years

Camelot allegedly existed once upon a time in South Wales. The name was evoked again in the 1960s, but perhaps it is also applicable to the character of rheuma­tology in the halcyon days of the 1970s and 80s. 

That’s not to belittle the world we now live in, with so many treatment options for our patients. However, something seems to have been lost in a half century. Rheuma­tology was predicated on the basics. Those included: 1) development of an encyclo­pedic knowledge of musculoskeletal and multi­system diseases; 2) assessment of patients utilizing a full history and physical; 3) vetted examination techniques specific to the specialty (e.g., the rheumatologic musculo­skeletal examination); 4) development of pertinent laboratory tests and recognition of their value and limitations; and 5) utilization of radiologic studies (rather than depending upon reports) and their interpretation to confirm clinical impressions.

Super-Internists

The rheumatologist at that time could be considered a super-internist, having all the skills of internists, but also an encyclo­­pedic knowledge and experience base to be able to pull together disparate, apparently unconnected information to make diag­noses and improve the quality of life of our patients. Our history taking was more encompassing, as was our physical examination. We would not think of taking on the care of a patient without having personally extracted the historical information and without personally performing a complete physical examination. 

Accepting diagnoses from any source outside one’s own assessment was unacceptable. We checked the basis for past diagnoses and how (or if) they were verified. This is exemplified by a patient I saw who claimed a diagnosis of Ehlers-Danlos syndrome was confirmed by prior physicians, but whose joint extensibility findings and polymerase chain reaction–DNA studies did not meet the criteria for that syndrome. 

Such recognition of erroneous diagnoses or inappropriate therapeutic inter­ventions is not always appreciated by patients, whether because of personal benefits provided by having a given diagnosis or because some other physician or the internet provided that diagnosis or approach. 

Inadequate provision of time and support staff by healthcare corporations to ensure patient understanding and comfort with the new validated information is reflected in lower patient satisfaction scores. In the corporate view, patient satisfaction trumps validity, quality and safety. Because patient satisfaction is used in determining reimbursement levels, it is an important metric. 

Rather than providing a mechanism with documented efficacy in patient communication (e.g., reinforcement of patient visit discussions), healthcare corporations seem to place income over people. Perhaps the downgrading of rheumatology practice in such environments is the response to such pressures; it is easier for the physician to simply accept previous diagnoses, perform minimal examinations and acquiesce to patient whims. After all, anything else takes time.

Double Check Lab Results

This obsessive-compulsive approach of those halcyon days extended to our resistance to accept laboratory results (e.g., the anti-nuclear antibody); we would repeat them either in our own laboratory or in one we had vetted. We reviewed all previous laboratory studies, identified others that would be helpful and personally examined their radiologic studies. That examination was not limited to X-rays of articulations, but also encompassed any previous radiologic studies. We even examined available histologic materials. 

Every field has its own search algorithm (i.e., the manner in which studies are physically examined). Most subspecialists felt we had skills complementary to those of general pathologists or radiologists who initially interpreted the studies. Whether this is related to failure of individuals ordering studies to provide sufficient clinical information to the pathologist or radiologist or whether that provided information distracted from their usual systematic evaluation, our reviews often provide additional perspectives. This is exemplified by a Radiologic Society of North America presentation titled The Chest Also Has a Spine.¹ General radiologists are skilled in the recognition of pulmonary pathology, but their search algorithm often does not include the axial skeleton. Compression fractures are often overlooked. 

Our field has long been evidence based, attending to quality of life, monitoring the efficacy and especially the safety of our interventions. This included timely performance of laboratory and other testing to assure safety of prescribed medications. We established standards (e.g., monitoring lab studies every one to three months for individuals on disease-modifying anti-rheumatic drugs, such as methotrexate).²

Attention to Detail

That seems very different from rheumatology today. I still practice with the same attention to detail with which I was trained. I find it quite disconcerting when patients new to me state they have previously seen multiple rheumatologists but have never had a complete examination; some even state they have never actually been examined. When I perform an examination of the joints of the hand and wrist, they express that this is a previously unexperienced phenomenon. 

I had thought this might be an isolated phenomenon, but have found it extending from one end of Indiana to the other, from the South Bend region to Evansville. Not only does a complete examination seem a foreign concept to patients in those areas, but so too is prophylactic laboratory test monitoring—maybe at six-month or, occasionally, four-month intervals, both outside the range of what has been referred to as usual and customary.² Are such shortcuts a response to required productivity, or are they channeled by fiscally driven organizations?

I’m not surprised when general radiologists fail to recognize compression fractures. That is outside the search images from their training. However, I find it most disconcerting when pulmonary nodules are also overlooked. Much of the problem may relate to attitude and denigrating lateral chest X-ray films. One article suggesting that they are no longer needed included an illustration of one such film.³ What they overlooked on the image they published were compression fractures and a lower lobe pneumonia.¹ Nodules visible on postero-anterior films were also overlooked.

The rheumatologist, as part of quality assurance, suggests that it might be worthwhile to intervene with additional attentiveness to such issues. During the time referred to as Camelot, identification of problems and offering solutions were not only appreciated but encouraged. Unfortunately, corporate hospital systems treat such internal observations as non-collegial. That led to the realization that current corporate hospital systems seem to have a problem with quality assurance. 

These healthcare conglomerates act as if their providers or staff have sold their souls to the company store. Healthcare corporations cutting pay during the COVID-19 pandemic illustrates a fiscal, not people or patient care-driven philosophy. Now quality assurance efforts are punished with attempts to gag the provider. Perhaps this explains why healthcare corporations typically refuse to accept “assuming due diligence, ethical behavior and non-compromise of patient care” as part of document signature. Even Medicaid accepts that codicil, recognizing its appropriateness. 

What I am suggesting is a return to the thrilling time of yesteryear. So the rheumatologist will ride again (with apologies to Jay Silverheels).

Bruce Rothschild, MD, is professor of medicine at IU Health and provides rheumatology services in Muncie, Indiana. 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.

References

1. Rothschild BM. The transcendental lateral chest radiograph. Radiography. 2014 Jun;
   21(1).
2. Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheum. 2016 Jan;68(1):1–26.
3. Osman F, Williams I. Should the lateral chest radiograph be routinely performed? Radiography. 2014;20(2):162–166.