Recommendation: Ultimately, the least problematic of the less-than-desirable options may be to continue to follow her at arm’s length, providing the medication and thus maintaining control of her disease.
Final Note: Recalling the time-honored adage, “no good deed goes unpunished,” last year the State of Massachusetts adopted laboratory monitoring for patients receiving methotrexate as a major quality indicator by which they tier rheumatologists. In Massachusetts, you might need to find a different resolution to the clinical scenario. The moral of the story: Know your local regulations before you do the right thing.
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Dr. MacKenzie is associate professor of clinical medicine and public health at Weill Cornell Medical College, Hospital for Special Surgery in New York. Dr. Kitsis is director of Bioethics Education and a member of the rheumatology division at Albert Einstein College Medicine in the Bronx, N.Y. Dr. Meltzer is assistant professor of medicine at Thomas Jefferson University in Philadelphia.
