ATLANTA—Clear communication with primary care physicians (PCPs) can be key to supporting timely care for patients with inflammatory conditions. However, knowledge gaps among PCPs about rheumatic diseases may delay patient diagnosis.
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Recently, a team of rheumatologists began evaluating electronic consultation (eConsult) communications to more fully understand common misconceptions among PCPs. The goal was to determine PCP knowledge gaps and identify areas in need of clarification, according to the study’s lead author Ruchi Jain, MD, a rheumatologist at Montefiore Medical Center, Bronx, N.Y. Dr. Jain presented the preliminary findings of this research at the 2019 ACR/ARP Annual Meeting in November.1
“Often, PCPs are on the front lines of patient care. By understanding rheumatic disease, they can deliver higher quality care, especially when there may be limitations to access, such as long wait times to see a rheumatologist,” Dr. Jain says.
In some situations, consult inquiry may be able to answer a simple question, without a patient undergoing an outpatient evaluation by a rheumatologist. eConsult can be used by a PCP to communicate electronically with a specialist, such as a rheumatologist, through a secure, web-based email, enabling the PCP to receive referral advice and to help the PCP choose the patient’s course of care and treatment. These interactions were the subject of investigation for this study, Dr. Jain explains.
A Closer Look at eConsult
To formally evaluate eConsult data for this study, Dr. Jain and colleagues performed a qualitative analysis of eConsult encounters that occurred between 2018 and 2019. Researchers used conventional content analysis to explore key themes in eConsult communications, including the questions and clinical histories of patients provided by PCPs and the recommendations provided by the consulting rheumatologist.
Often, when a patient is referred to a rheumatologist in the outpatient setting by a PCP through traditional channels, the referral form will just say “gout management” or “joint pain.” But through eConsult, “we can assess the clinical information provided by the PCP and see where the knowledge gaps truly are and tailor our recommendations to [enable] PCPs to take better care of their patients,” she says.
During this study, examples of PCP misconceptions and knowledge gaps included overdiagnosis of polymyalgia rheumatica (PMR), understanding the role of autoantibodies along with the usefulness of serological tests in patients with non-specific joint pains/arthralgias and differentiating between inflammatory and non-inflammatory arthropathy.
Some elements of the analysis surprised Dr. Jain, such as the amount of time PMR was given consideration as a diagnosis by PCPs.
“I was also surprised by some of the reasons given why serologic and auto-antibody tests were checked in patients with non-specific joint pain, along with the number of times high-sensitivity C-reactive protein (CRP) was used rather than regular CRP in assessing systemic inflammation in rheumatic diseases,” she says.
Beyond the findings of this investigation, Dr. Jain and her study co-authors have investigated eConsult data regarding differences in the need for future outpatient consultation between rheumatology and other medical subspecialties. They’ve also examined the development of tailored educational content for internal medicine residents and internal medicine physicians based on specific cases of eConsult communications.
So far, this investigation “highlights that, in rheumatology especially, the diagnosis and management of many of our diseases truly rest on a thorough history to look for subtle clues, as well as the physical exam with lab tests that often … help support our clinical suspicion of a disease process,” Dr. Jain says. “Although there is value in eConsults reducing the need for face-to-face consultation in certain specialties, for rheumatology the value of the eConsult rests on triaging urgent vs. routine outpatient visits, along with an educational role of enriching practice-based learning.”
Opportunities to Educate
This analysis of eConsult communications revealed common themes in both PCP questions and rheumatologist recommendations, underscoring areas for further education, according to Dr. Jain. She believes targeted education addressing such knowledge gaps may “be applied at the internal medicine resident level. [This level will] capture the highest yield [to address] the most common types of questions and eConsult questions asked of the rheumatology eConsultant.”
Carina Stanton is a freelance science journalist based in Denver.
- Jain R, Broder A, Rikin S, et al. Identifying educational themes and knowledge gaps through analysis of electronic consultation (eConsult) communication between primary care physicians and rheumatologists [abstract #1796]. Arthritis Rheumatol. 2019 Oct;71(suppl 10).