Who is my ideal arthritis patient?

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

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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:
 
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How many patients does a Rheumatologist see?

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CalcBy Dr Irwin Lim, Rheumatologist

As a director of an arthritis service with 7 rheumatologists, I do have an interest in stats.

As I finished up seeing my last patient at midday on the 31st December, it occurred to me to quickly check how many patients I’d seen for the calendar year.

I know many rheumatologists who see patients at a faster rate, and I also know rheumatologists who take more time with their patients than me.

So, when interpreting these figures, you need to know a little more about my timetable:

  • My new patient consultations are 45 minutes long. Follow up consultations are scheduled at 15 minute intervals.
  • I took 4 weeks annual leave.
  • Time away on conference totalled 3 weeks.
  • The figures do not include patients who have booked and then don’t bother showing up.
  • I generally work 7-8 clinics a week where I see patients, with 28-32 hours reserved for direct patient contact (the rest of my week involves meetings or administrative type work).
  • The figures don’t include phone calls, emails, paperwork.

Between 1st January and 31st December, I performed (rough figures generated by our patient management software):

  • 677 new patient consultations
  • 2820 follow-up consultations
  • 79 telehealth video consultations with patients living in rural Australia
  • 332 ultrasound examinations (with Lisa, our ultrasonographer)
  • 138 joint injections (an underestimation as we don’t track all of these)

That’s roughly 72765 minutes of patient contact over 45 working weeks.

77.7 patient consultations per week.

Now that I’ve calculated this, it doesn’t sound like that many.

But, at the risk of sounding a bit wimpy, it still feels like hard work at times.

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.
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Slow Rheumatology

By Dr Irwin Lim, Rheumatologist

My wife and I were given this book by a friend a couple of years ago. It contains some good insights which I think she thought we needed (and she needed herself).

Slow

I’m sure you know how we feel. Often time poor, with every increasing demands. Patients needs. Staff wants. Business must-dos. Family essentials.

We’ve instituted a few things to slow our lives but more can be done.

A large part of my mission in life is to be an effective person, and that includes, being an effective rheumatologist.

I’m a naturally speedy person so for me to improve myself, I know I have to learn to be slower and to take more time with people and with important stuff.

So that’s my New Year’s resolution for 2015.

I share it with you because I find that by writing things down, I’m more committed to the task and tend to make it happen.

Hourglass2The 3 big practical steps I’m taking:

  • This little hourglass now sits on my workdesk. I don’t actually need to turn it to see the sand flow. As I feel rushed, I’m just going to look at it. My visual cue.
  • Get better at saying “No”. There are many requests, demands, invites to be dealt with. Guilt and a sense of responsibility can often lead to saying yes too often, and that leads to an increasingly packed calendar. I’m going to be a polite refuser.
  • From April, I’ve blocked off all my patient appointments on Wednesdays. A very big step for me. Less time to see patients but a day to do the stuff that always piles up when one if consulting. Also a day to attend to my own needs: exercise, reading, thinking, etc…..

Welcome 2015!

I wish you all a great year, with effective time & good health to pursue your resolutions.

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.
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Methotrexate & Laser Hair Removal

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Image courtesy of stockimages at FreeDigitalPhotos.net

Image courtesy of stockimages at FreeDigitalPhotos.net

By Dr Irwin Lim, Rheumatologist

Today, my patient with longstanding rheumatoid arthritis asked me whether she could stop Methotrexate. Her disease is well controlled and she is on another disease modifying agent concurrently.

The reason?

She wants to have laser hair removal on her legs. But the cosmetic salon she visited refused because she is on Methotrexate.

She asked my opinion. My considered opinion was that I didn’t know.

I can’t imagine there’s any research on this matter. I’m sure no-one is designing a trial to laser a bunch of females on Methotrexate to see what happens.

I assume the worry for the laser practitioners is the possible photosensitivity while on Methotrexate. Many other medications may cause photosensitivity so I assume patients on those medications must be similarly rejected. Rather than take any risk, I think a blanket rule is being applied.

In her case, I was happy to trial a reduction in Methotrexate and if the disease remains well controlled, we will try to cease the medication. But I might not be so keen to cease Methotrexate in other patient scenarios.

So, I thought I’d ask.

Have any of you had laser hair removal while on Methotrexate? How did it turn out?

Are any of you aware of any information that will educate me on 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:
 
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