Wow. That’s the first word that came to my mind as I read the responses to my recent “Rheuminations” article about a difficult gout case. The point of my article was that, even with a condition as seemingly simple as gout, complexity intrudes and can wreak havoc with even the established approach to patient care.
I felt a “wow” quality for several reasons. First and foremost, I was excited that readers took the time to write in and share their opinions. Writing is a lonesome calling and, while I send a blizzard of words into the world on printed pages and the electronic beams of cyberspace, until I get a reply, I live in a vacuum.
Via countless e-mails, I hear regularly from Medscape, lonesome Olga from the frozen steppes of Siberia, and a host of companies hawking products to soup up my ELISAs. While there is some comfort in receiving any email—it is a sign that I am alive and someone thinks I am of value—I really want to hear from you, my readers. Did you like what I wrote? Did my words connect? Did I make sense? I am therefore thrilled by the volume of responses.
To the contributors whose replies are printed on page 8, I say a sincere and heartfelt “thank you” for reading and writing.
From what I have been reading about the looming disaster on healthcare financing, we should have a “pray-for-performance” initiative.
“Best” Treatment Choice?
The second reason I felt a “wow” quality is the recognition that there are a slew of ways to treat gout in the patient I described. To eliminate any suspense, my preference would be a brief course of glucocorticoids. My preference here is most certainly not evidence-based, primarily because there is no evidence. Rather, I like a course of prednisone because it fits my treatment philosophy (not invasive if I don’t have to be) and, on the occasions where I have had a similar clinical situation, it has worked very well.
Could I have justified a course of adrenocorticotropic hormone (ACTH)? Absolutely. Intra-articular steroids? Sure. Intravenous colchicine? Maybe or maybe not. On the basis of science, I think colchicine would be a great choice—it stops the inflammasome in its tracks—but the literature describes nastiness with this drug. I do not want to ravage the bone marrow for a joint problem that will likely go away by itself.
Now that I have discovered compadres out there who like to think about gout, I promise that soon you will have another case to chew on. I think that the next one will be harder and, frankly, I need advice.
The third reason I had a “wow” feeling concerns the ongoing discussion about quality that bears on the pay-for-performance initiative. From what I have been reading about the looming disaster on healthcare financing, however, we should also have a “pray-for-performance” initiative.
I would like to ask you some questions. Do any of the different approaches to the management of gout I described represent more quality than the others? Is there one approach that would be demonstrably better or more solidly grounded in data? Are they all equal?
My argument is that, within limits, every approach described in fact represents quality and is based on experience, informed judgment, and a serious and sober assessment of the risks and benefits.
Some physicians may worry more about creating a hemarthrosis than others, but the extent of that worry likely relates to the number of joint taps performed previously with a patient on anticoagulation. If a physician has never had a bad outcome, he or she is likely to feel confident about sticking a needle in a joint when the INR (international normalization ratio) is 3.
On the other hand, if the physician had once caused a bleed, heard a colleague tell of a mishap, or been asked to serve as an expert witness in a lawsuit about such a circumstance, the needle would stay in its protective sheath, safely away from the red, throbbing joint.
In the same way, someone who has seen the blood count plunge after a slug of colchicine would likely never go that route again.
Side Effects Aside
The issue is not just side effects.
If, on too many outings, prednisone tapers or doses of ACTH failed to calm the gout, trust me, it would soon be needle time. For both the specialty and the individual practitioner, therapy evolves. It is not set in stone. Physicians are not idiots. They do what works and they stay away from what harms.
While I am for quality improvement as much as anyone, I worry that we may be going in the wrong direction. Because the world has computers, there is an illusion that these machines—as slick and as fast as they are—can simplify, quantify, and render judgments on the decision-making in some of the knottiest and most vexing clinical situations that can be imagined. Even with the best algorithms in Googledom, medicine is a tough nut to crack.
We are embarking on a great experiment in the delivery of healthcare. Like all good experiments, this one has a hypothesis and the hypothesis is that we can improve care by offering providers incentives for quality. That is a very worthy goal, but the big and untested assumptions are that we can measure quality and that the incentives are sufficient to change behavior—to the extent that behavior needs to be changed. Of course, we can change the equation by reducing reimbursement for lack of quality, but let’s not go there right now.
At times like this, as I look at the future of my specialty, I feel like the patient who has gout. I am in fear. My anxiety is high and, in anticipation of the next attack (in this case, more regulations and bureaucracy), I worry that a wave of fearsome and flaming pain is rushing toward me.
An I a realist or a Chicken Little when it comes to the future?
Please write in to [email protected]. You helped me on my last case. Now help me on this one.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.