Standards are there because we practice in an environment of evidence-based medicine. That approach saves lives and is at the heart of rheumatology—attention to the restoration and preservation of the quality of life.
Why Deviations from the Standard of Care Occur
When physicians are unfamiliar with standards of care, it’s also the patient’s dilemma. When informed of the need for monitoring, the patient may feel it’s excessive and, appropriately, ask their primary care physician. The primary care physician, being unaware of the standards and not discussing the matter with the rheumatologist, may not support that rheumatologist’s approach. Thus, the patient may feel caught in the middle between two physicians. Or the patient may perceive the monitoring as inconvenient or expensive.
Of course, expenses do pale when compared with the fiscal and health (morbidity and mortality) expenses of late discovery of medication-induced pathology (e.g., liver or kidney failure). So convenience seems a poor rationale for deviating from standards of care. But what of expense?
As insurance companies raise co-pays, office visits become an additional expense, although a lot less than the cost of treating side effects discovered late. What co-pay amount is a burden? Perhaps the following anecdote will provide insight:
A 23-year-old woman presented with rheumatoid arthritis. Examination revealed a subtle breast mass. Her primary care physician had told her that “it was not significant.” I was sufficiently concerned to immediately send her for a mammogram. The mammogram documented cancer.
She had surgery and chemotherapy. The latter also brought her rheumatoid arthritis into remission. When chemotherapy wore off, her rheumatoid arthritis became active again. Specific treatment was initiated, with remission established. Subsequent evaluations were at three-month intervals to ensure regimen safety.
One day, she informed me that she had changed insurance. Her rheumatology co-pays would now be $10 more per visit. She recognized that my conscientiousness had saved her life. But she wanted to save the additional $40/year that came with the monitoring.
Adherence to standards of care provides a safety net for both patients & physicians.
Do limitations, such as high premiums, represent practice of medicine by non-physicians? Perhaps, insurance-related impediments should be examined as representing insurance company co-liability. And of course, patients with chronic diseases that require monitoring need to consider the additional cost of appointments and tests when choosing their insurance companies.
What about the other components of safety surveillance appointments—work schedules and travel expenses? The Americans with Disabilities Act should address the former. Insurance companies have the obligation to ensure access to the care for which they claim access and, if travel is required (because of the location of their network physicians or lapses in that network), should that not be their responsibility? Perhaps this represents a future matter for regulatory agency consideration.
Summing Up
When habit and evidence collide, the outcome appears to depend on commitment to the conscientious practice of medicine that defines and maintains its quality. Health outcome and medical–legal exposure are, of course, tempered by susceptibility to bullying by those committed to convenience and area habits. R
