Two sides of the Rheumatology Coin

7
Image courtesy of Arvind Balaraman at FreeDigitalPhotos.net
Image courtesy of A.Balaraman at FreeDigitalPhotos

 

By Dr Irwin Lim, Rheumatologist

I was involved with some interesting market research. It involved a “good cop, bad cop” scenario.

I was asked to place myself in the position of a rheumatologist who was strongly advocating the use of biologic medication in a patient with ankylosing spondylitis. I spoke to an empty chair explaining my case.

The imaginary patient was, for this scenario, very nervous about the medication, because she had a very strong family history of multiple sclerosis (this is a complicated situation given some case reports of multiple sclerosis on TNF-inhibitor therapy).

My case was strong, and I put it forward reasonably confidently. The benefits outweighed the risks, quite clearly.

Next, I was asked to move to the empty chair.

This time, I was asked to play the role of a rheumatologist who was not an advocate of using biologic medication in this same hypothetical patient.

This was a harder role to play.

Why would I wait and work on alternative measures, eventhough I believed these were going to be less effective? The argument was based around the angst such a decision would cause this patient, and how her perception of risk was so great that it would be better to err on the side of caution to give her peace of mind.

After this role playing, I was asked to describe my behaviour as a rheumatologist in the 2 scenarios in 1 word.

Again, I found this hard to do. I chose the words, paternalistic vs patient-centred.

I’m not quite sure if they were the right words. And I’m not quite sure of the point of the exercise. But it provided food for thought.

Everyday, I think rheumatologists play either role depending on the different scenarios which unfold in our consulting rooms.

Do you agree?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address:
Delivered by FeedBurner

Rheumatoid: good but not perfect

9

By Dr Irwin Lim, Rheumatologist

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address:
Delivered by FeedBurner

This picture of RA needs to be changed!

9

By Dr Irwin Lim, Rheumatologist

Rheumatoid Hands: late disease

Rheumatoid Hands: late disease

 

Textbooks. Websites, Information Sheets (including ours).

All to be blamed to some extent. Pictures like this are used to teach and inform. Unfortunately, an image like this sticks. People remember.

And this may be an issue.

Most of my patients with inflammatory arthritis do not have hands that look like this. They present earlier, and this typically allows better control of disease and improved longer term outcomes. Most avoid deformity like this.

We can’t afford doctors, physiotherapists, chiropractors, osteopaths, nurses, patients themselves to wait till their hands become deformed to be properly diagnosed and appropriately treated.

We can’t afford to have health professionals miss inflammatory arthritis just because the hands look “normal”.

It’s fine to show pictures like this as long as we put them in context.

What do you think when you see a picture like this? Does it represent your disease?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address:
Delivered by FeedBurner

Who is my ideal arthritis patient?

4

By Dr Irwin Lim, Rheumatologist

I was recently completing a questionnaire and this question faced me.

Who is your ideal target customer?

Hmm.

We want to help everyone of course but it’s probably not a surprise to you, that some patients click with some doctors, and some doctors click with some patients.

I thought about this for a few minutes, in the context of the clinic I work in and the resources I use, and came up with:

  • The patient who is motivated to get better, the person who is engaged in their own care.
  • Ideally, someone who believes and understands that best care does involve input from a variety of different health professionals working together as a team.

I wonder what your thoughts may be about this?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address:
Delivered by FeedBurner

Maybe you should check the cause for Carpal Tunnel Syndrome prior to Surgery?

0

By Dr Irwin Lim, Rheumatologist

Carpal tunnel syndrome is common. After feeling pain, tingling, numbness and/or weakness in the hand for some time, the sufferer seeks some medical advice.

The diagnosis can be made by the description of symptoms and a physical examination of the wrist and hand.

It’s common for patients to have a nerve conduction study, which is a test that helps work out if the median nerve is irritated or damaged. This nerve sits in the carpal tunnel (click for anatomy) with pressure on the nerve leading to the symptoms.

Treatment tends to be directed at avoiding aggravating activity, the use of wrist splints, and then, surgery to the carpal tunnel to take pressure off the median nerve if conservative measures do not work.

As a rheumatologist, I see a skewed number of patients with carpal tunnel syndrome who may not need or may not have needed carpal tunnel surgery.

I write a lot about inflammatory arthritis. When people, including doctors, think about an arthritis, they concentrate on joint disease. But, it’s equally important to think of the tendons. The tendons may swell. Their coverings or lining, the sheaths, can become very inflamed.

Now, the carpal tunnel contains the median nerve and a whole bunch of tendons, tendons which work to flex your fingers.

When the tendons and their sheaths are affected by the underlying inflammatory arthritis, they swell and the space within the carpal tunnel gets tighter and tighter, with the median nerve becoming squashed.

This happens with rheumatoid arthritis. It happens with psoriatic arthritis and spondyloarthritis. It can happen with many of the inflammatory diseases rheumatologist treat.

In these cases, surgery may well not be required.

We would aim to reduce the swelling within the tunnel. A cortisone injection directed to the inflamed, swollen area can help settle the problem as an adjunct to longer term treatment of any underlying disease.

Underlying inflammatory arthritis presenting as carpal tunnel syndrome is often not picked up early.

A simple, readily available examination which would quickly show the state of the nerve and the underlying tendons is an ultrasound. It does however require the health professional assessing the problem to be cognizant that inflammatory causes exist.

 

Ultrasound Image: Cross-section of Carpal Tunnel. (SCAP = scaphoid, PISI = pisiform)

Ultrasound Image: Cross-section of Carpal Tunnel. (SCAP = scaphoid, PISI = pisiform)

Ultrasound Image: Longitudinal view (MN = median nerve, FT = flexor tendon)

Ultrasound Image: Longitudinal view (MN = median nerve, FT = flexor tendon)

 

I think there are some situations where more investigation or considered thought should occur prior to surgery. These include:

  • a person presenting with BOTH hands being affected. Suspicious.
  • when the carpal tunnel symptoms occur in the setting of other joint problems (especially if there is already a known rheumatological diagnosis). This requires a careful history.
  • when it occurs in a young individual for no apparent reason. By that I mean, there’s no obvious aggravating activity to cause the problem.

What’s your experience with carpal tunnel syndrome?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address:
Delivered by FeedBurner
Page 1 of 6912345»102030...Last »