Can patient & rheumatologist agree on the target?

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By Dr Irwin Lim, Rheumatologist

Treat-to-target is a term bandied around a lot in rheumatology circles.

I’ve written about some issues when dealing with targets which aren’t necessarily that well defined or easy to achieve (read here).

I listened to a talk on the weekend on patient reported outcomes and I couldn’t resist taking a photo of this cartoon while it was on screen.

Different targets

It nicely highlights that what patients want to achieve with treatment may not always be what the doctor seeks to achieve. The 2 groups sometimes speak different language.

Or they’ve missed the important step of negotiating and communicating shared goals.

I’m often guilty of launching into the rationale for my treatment plan:

“We need to do X so that we can achieve Y”

The cartoon reminds me to also be more explicit in asking the patient in front of me:

What’s your goal?

What do you want to get out of the treatment of your problem?

It seems pretty evident that agreeing to shared treatment goals would improve patient-Dr relationship and workflow.

It might even improve patient compliance. It will likely improve the effectiveness of the doctor.

Does your doctor ask you what your targets are?

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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An afternoon of rheumatology with GP registrars

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Image courtesy of jesadaphorn at FreeDigitalPhotos.net

Image courtesy of jesadaphorn at FreeDigitalPhotos.net

By Dr Irwin Lim, Rheumatologist

Yesterday afternoon, I had the opportunity to speak to 70 General Practice registrars (trainee-GPs) at the Wentwest training facility in Blacktown, a hub in Western Sydney.

It was the post-lunch session. I had 1 hour and 45 minutes.

The brief – An update in Rheumatology.

1 hour and 45 minutes is not enough to update all of Rheumatology.

To fight post-prandial sleepiness and to improve the chance of my messages sticking, I chose a case-based format and prepared 4 patient-based presentations to try and stimulate discussion.

I was relying on discussion, so I coaxed and badgered.

Case 1: Male generation-X’er presenting with a swollen ankle and big toe.

Easy case of gout but what I wanted to highlight was the process of differentiating a mechanical/degenerative cause from an inflammatory cause for arthritis.

What bits of the history help? What should GPs be looking for in the examination to help them work out possible causes? How do we make educated guesses about the probabilities of various diagnoses?

We also had to discuss how to and how NOT to use allopurinol and colchicine, common medications commonly poorly instituted.

Case 2: Older, middle-aged female with swelling in her “knuckles” and wrists, with some symptoms of carpal tunnel syndrome.

Straight-forward case of rheumatoid arthritis. It was nice to hear how the GP registrars approached appropriate investigation. As always, the topic of Methotrexate was brought up and we addressed the common problem of patient reluctance to take this medication.

Not unsurprisingly, the GP registrars knowledge of disease-modifying drugs (DMARD) was not extensive. At least, some had heard about biologic DMARDs although none had actually been involved in the care of a patient on a biologic DMARD.

Pleasingly, there were doctors in the room aware of the need for early treatment and the concept of the window-of-opportunity. I took the chance to hammer than nail a few more times.

Case 3: Male baby boomer presenting with years of tender joints, various tendon problems, a stiff back and not much to see in terms of swelling at the joints.

Made the point that those non-so-subtle nail changes might be helpful. As well as the patch of scaly skin on the scalp.

A case of psoriatic arthritis. A frustrating disease, with the diagnosis so often delayed. We discussed why rheumatic disease diagnoses and treatments are so often delayed.

We discussed advances in understanding how the disease develops, we discussed the difficulties with the labels we currently use for diseases and how many autoimmune diseases can be difficult to work out, confusing and frustrating patients and doctors.

Case 4 was to be about chronic back pain. Many GPs don’t enjoy treating this.

We didn’t get to case 4 due to the level of discussion.

And while it was my voice mainly, there were enough questions and comments, and feedback to make me feel it was a worthwhile session.

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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Two sides of the Rheumatology Coin

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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.
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Rheumatoid: good but not perfect

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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:
 
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This picture of RA needs to be changed!

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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:
 
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