I was a staff physician-rheumatologist at the Mayo Clinic in Rochester, Minn., for 25 years. For the last nine years I’ve been physician-rheumatologist at Emory University School of Medicine in Atlanta, primarily at Grady Hospital. Mayo is a mecca for rheumatology, while Grady is a prototypic public hospital. The experiences at these institutions have been vastly different, yet one has allowed me to succeed in the other.
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Explore This IssueSeptember 2007
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Path from Plenty to Paucity
I took my medicine residency and rheumatology fellowship at Mayo, then I joined the staff where I spent the next 25 years practicing rheumatology in an efficient, integrated medical care system. It was easy to deliver high-quality care in that environment. The system was designed to be efficient, stimulating, and interactive for the physicians and surgeons on the staff. I also had the opportunity to teach, conduct clinical investigation, and contribute to the literature—primarily in the area of vasculitis—and I was involved in administration.
I came to Atlanta to be medical director of the National Arthritis Foundation, but got involved at Emory right away, helping staff the arthritis clinic at Grady on Mondays. After three years at the Arthritis Foundation, I went to Grady full time, and the following year I became director of rheumatology at Emory. Between 1999 and 2007, I build the fellowship program, expand the staff, and got clinical investigation started.
Rheumatology at Grady
I want to focus on the rheumatology patient population at Grady, and the challenges and opportunities there. The majority of the patients are African Americans—usually with no insurance or on Medicaid. Many have no jobs or are part of the working poor. We see a spectrum of rheumatic diseases and have large numbers of patients with osteoarthritis (primarily of the knees), rheumatoid arthritis, lupus, and gout.
What are the challenges in seeing patients at Grady? We have paper charts, but cannot easily retrieve charts from other clinics, such as orthopedics, neurology, and dermatology. It is impossible to get timely consultation. We can get routine labs and X-rays performed and results back in good time, but for examinations like CT or MRI, it may take a month to get the test done.
On Mondays the Grady arthritis clinic is the continuity clinic for our six rheumatology subspecialty residents. We also have two or three internal medicine residents on Monday. In our other clinics we have one subspecialty resident and several medicine residents. Our challenge is to provide the best care possible and, at the same time, make this a good educational experience.
I could not have met this challenge earlier in my career in this setting with this patient population. Earlier, I did not have the knowledge, the patience, and— particularly—the experience or confidence. After more than 35 years in rheumatology, I have seen most of diseases and conditions that present to us. At Mayo, I had the benefit of an efficient system, with all tests at my fingertips and consultations readily available, and I learned what is needed to evaluate patients in most circumstances and when a consultation is helpful.
Using my background from Mayo, I can usually obtain from the history and targeted physical examination the information needed to make the diagnosis for my patients at Grady. Then, even with a limited formulary, we can do a good job of treating the patient. Usually, we are not handicapped or delayed in diagnosis because of lack of tests or consultations. The lack of an extravagant formulary has not deterred the appropriate and effective treatment of our patients. As a matter of fact, we probably practice much more cost effectively than institutions where resources are abundant, and I suspect our outcomes are comparable.
Patients in Need
What about the Grady patients? Are they less compliant, less reliable, and less appreciative? No. Like patients everywhere, they want their condition to improve and they want to cooperate with their physicians. I have learned from them and, when they miss an appointment or are delayed or if they have not taken their medicines, there is usually a good reason. Many of our patients depend on public transportation, and this process is often time consuming. Their finances are frequently limited, and they have to make hard choices between paying for rent, food, transportation, children’s needs, and paying for medications. Sometimes, the medicines are sacrificed.
It is difficult to put oneself in another’s shoes, but only by doing this can you understand what these patients confront and how they may think. I constantly try to learn from my patients and understand the factors that influence their lives. I try to help them understand their disease and what we are trying to do, and make their treatment program simple, understandable, and relatively inexpensive. Yet I realize that for these patients even coming to the doctor can be difficult.
At Grady, patients must endure long waits to be seen, get tests, and get medicines. We are constantly under financial pressure to reduce costs because 40% of the patients seen do not pay for their care, and the government at all levels is insidiously reducing payment for the care of the poor. As a result, the staff is reduced and the equipment, computers, and systems are old. At the same time, there are more and more patients in the Atlanta area without insurance or jobs who seek care at Grady. The result is slow, inefficient care.
Despite these obstacles, at Grady we strive to care for these patients in the best fashion possible. This is the commitment of the nurses, attendants, residents, fellows, and staff in the rheumatology division and arthritis clinics at Grady. For example, we have an early arthritis clinic at Grady and we see many patients with early rheumatoid arthritis— mostly African Americans but more and more Hispanics. We use the treatment modalities available—namely low dose prednisone, methotrexate, sulfasalazine, and hydroxychloroquine— early and in combination and achieve outcomes comparable to what is in the literature using anti-TNF agents.
The journey from Mayo to Grady is as long as any in American medicine. It has been educational, stimulating, and insightful. In the Mayo phase of my career, I was not tuned in to the social and economic issues influencing my patients because it was not necessary for their care. At Grady, I have been forced to consider the social and economic forces influencing my patients because those factors determine my patients’ health as much as anything else. My greatest disappointment in working at Grady is the realization that our government—both local and national—disregards the health of the poor. Nevertheless, I have hope that this situation will change and that America will one day deliver equal care to all its people.
Dr. Conn is professor of medicine and director of the division of rheumatology at Emory University School of Medicine.