Tips for Setting Treatment Goals with the Patient

In light of this, it is important that a rheumatologist emphasize the rapid advances in the understanding of the pathophysiology of many common rheumatic diseases. Optimization of disease control for many rheumatic diseases can now be done along with minimization of risk to the patient.

Risk aversion is often due to a patient’s lack of education regarding the nature of the underlying disease and the long-term implications of suboptimally treated disease vs. the real risk of medication side effects. “These conversations take time, but the rewards for the patient can be life changing,” Dr. Ware says. “Optimization of disease control is not taking a risk. In fact, not optimizing disease control is potentially the riskier behavior in the long run.”

Dr. Perl

Dr. Perl frequently encounters patients who have difficulty understanding that rheumatic diseases are chronic and may have serious consequences if left untreated. “Consequently, it is very common for patients to abandon treatment because they didn’t realize that they [would] have to take medication forever,” he says. “I tell patients that even though their newly diagnosed disease is manageable and that the goal is to live a normal life as much as possible by managing their disease, they need to take medications as prescribed and have regular doctor visits and monitoring via laboratory tests.”

Setting Goals

Many patients arrive at their appointment with treatment goals in mind. Some want pain to resolve. Others want to be able to maintain employment until eligible for retirement. Others need to balance work with an active home life. After the patient expresses these goals, the rheumatologist can individualize a treatment plan that keeps these goals in mind while maximizing treatment benefit, Dr. Ware says.

For patients looking to determine and set their goals, having a clear communication strategy is key. Patients who accept treatment should be informed of the treatment length, the expected benefits and the possible side effects of treatment and how often they will need doctor visits and laboratory testing. “All of this is meant to ensure that they are able to adapt to the new routine in the best way,” Dr. Bonilla says. “For patients who refuse treatment, I inform them about the [potential] consequences of their decision.”

Dr. Goodman has found that the more time she spends on education up front, the easier long-term disease management will be. “With recently diagnosed patients, it helps to begin with simple goals, such as decreasing pain,” she says. “Decisions about long-term goals don’t have to be made at the first visit, but can be part of an ongoing dialogue. In some situations, decisions and goal setting are driven by specific priorities.” Pregnancy, for example, creates specific challenges and rewards. The discussion about certain medications, such as methotrexate, is very clear in this context (i.e., recommend stopping use prior to becoming pregnant to reduce the risks of miscarriage, birth defects and more); however, the use of biologics during pregnancy is more complicated and nuanced.

Goal Implementation

Dr. Goodman asks patients not to make drastic, permanent changes immediately after receiving a diagnosis of RA. “Most patients will respond well to therapy, and although they feel exhausted, are in pain and may feel anxious and vulnerable at the onset, they’ll be better able to assess their long-term goals regarding employment or social participation after beginning to respond to treatment,” she says. Often, short-term goals are to decrease pain and fatigue, with an explicit plan of considering long-term goals, such as beginning an exercise routine or smoking cessation, at the next visit.