Friday, October 13, 2006

Rheumatology and other things Current mood: busy Since this is a first post, I'm not quite sure where to go. I don't know if I have a direction, or if I'll post regularly. Just comments, professional and personal, on what interests me. Last night, I attended a dinner sponsored by the Northwest Chapter of the Arthritis Foundation, featuring a lecture by the eminent rheumatologist, Dr. John Klippel. Dr. Klippel is the current CEO of the Arthritis Foundation, as well as being a celebrated researcher, teacher and clinician. At least one of the references in my office list Dr. Klippel as the primary author. His talk was heard by many of the luminaries of the Northwest rheumatology community, including Dr. Peter Mohai, Dr. Peter Simkin and Dr. Carol Wallace (Children's Hospital Pediatric Rheumatologist). The focus? Arthritis recognition in the community. Millions of Americans suffer from some form of arthritis or autoimmune disease, yet many of these people have never seen a rheumatologist. I am continually amazed at the patients I see in consultation, who have had diseases such as active Rheumatoid Arthritis for months or even years without treatment. In many of these diseases, early intervention means the difference between function and permanent disability, or damage to joints that could otherwise be spared. At many levels of care, however, there seems to be no sense of urgency when approaching the patient with arthritis. Given that the most common cause of joint pain in the United States is osteoarthritis, which is a slow progressive hypertrophic disease, one would think this to be the reasonable course. Treatment of this disorder at primary care level is quite legitimate, provided proper monitoring of prescription drugs is possible to prevent adverse reactions. Inflammatory arthritis such as Rheumatoid Arthritis, however, can cause irreparable damage to bone and joints within months of initial onset. Once damaged by erosion, there is little that can be done to regain the lost bone. Evaluation of arthritis should be as urgent as that of malignancy. Today alone, 1500 joint replacement surgeries will be done, and arthritis of all types will cost the country over 400 million dollars in treatment, lost work and productivity, disability claims and more. Worse yet, autoimmune diseases such as Systemic Lupus Erythematosis are quite capable of killing a young patient if not attacked with all fervor. I lost one patient last year, a young man of eighteen, to lupus that was not initially recognized and referred. Making the problem worse, there is a nationwide shortage of Rheumatologists, with no end in sight. Why would this be, in an age where science has advanced the practice and outcomes by unprecedented degrees? For the first time, rheumatologists are using the word "remission" when talking about rheumatoid arthritis. Why, then, are there so few of us practicing? Money, of course. Medical students learn more than medicine these days. Being a doctor or even a midlevel practicioner such as a PA is as much a business proposition as a service. The money in medicine is found in procedures. A cardiologist who does angiograms and pacemaker placements will make many times more than a clinical rheumatologist. Outside of joint aspiration and injection, there are few procedures performed by the rheumatologist in the office. We are, interestingly, considered to be problem solvers, often referred to as the "court of last resort" in cases where other specialties are left shaking their heads. A recent New York Times Magazine article (registration required) put it well: ...when the patient has already seen other doctors before arriving at your door, you need to approach the case with a different mind-set — with different assumptions. You know, for example, that whatever this patient has, it isn't going to be obvious. Maybe it's an unusual disease, known best by specialists, or perhaps it's an unusual presentation of a more common illness. In any case, it won't be routine. The rheumatologist, however, receives far less for his problem-solving skills than the physicians who do test after test before sending to our door. This isn't all about money, but that is a big minus in the eyes of a young medical student with $200K in student loan debt. Many of the groundbreaking medications used in our specialty are expensive enough to be out of reach to all except the well-insured. There are programs to help, but some people fall through the gaps. The science is sound in showing the benefit of these treatments, but like too many areas in our country, the poorest are the last to receive these benefits. Despite this, the science is very good. The biochemistry of immunology is advancing by leaps and bounds, with many more drugs becoming available soon for RA, osteoporosis, lupus and other diseases. These are the problems inherent in our specialty. In the next blog, I'll talk about the attractions, and some possible solutions. Please feel free to comment.