Rheumatologist Steven S. Overman Reflects on His Last Day of Practice, Future of Specialty

Letterman is gone, so I won’t give my 10 in reverse order. Rheumatologists are prepared to lead the way because they:

1. Are great docs: Dr. Carkin reminds me that rheumatologists are the best at history taking and pattern recognition—patterns that don’t show up on imaging studies, but when identified will reduce the use of diagnostic tests and procedures.
2. Are collegial: Sue reminds me that a problem too tough for one rheumatologist may not be too tough for two. Because we associate with other greater clinicians and aren’t afraid to ask, building networks of excellence won’t be difficult.
3. Understand complexity: Alice reminds me that we take care of some of the most complicated, costly patients in outpatient medicine. Are you adequately compensated for all of the elements of decision making and care you provide for such patients?
4. Have a need to be accountable: Grant reminds me that many undiagnosed patients need access to our care. Only by committing to a system of population management may we ensure this happens.
5. Understand inflammation in disease: Stormy’s 10/10 pain reminds me of the extreme pain that inflammatory chemicals create. Rheumatologists’ understanding and treatment can be of high value in settings where others treat only what they can see (i.e., anatomic abnormalities—acute lumbago pain [possible discitis], acute post-op rotator cuff surgical pain [possible post-inflammatory sensitization], knee sprain ‘meniscus’ pain [possible inflammation and sensitization], acute TMJ pain [possible arthritis], sacroiliac dysfunction pain [possible sacroiliitis], forefoot degenerative joint disease pain [possible inflammatory arthritis], post-op swelling and pain possible [possible acute pseudogout] or “fibro flare” pain [possible enthesitis/bursitis]).
6. Understand multifactorial illness models: Grant reminds me that stress, the microbiome and the environment may trigger inflammatory disorders, and inflammatory disorders can be associated with metabolic problems, possibly causing weight gain, sleep apnea, chronic fatigue and chronic central sensitization. We have many inroads for making a difference.
7. Understand collaborative care and combination therapies: The university pain doc reminds me that not only can central sensitization be associated with the generalized pain of fibromyalgia, it can also be part of the tenderness to touch in patients with OA knee pain. Combination strategies for treating pain may help delay arthroscopic and joint replacement surgeries.
8. Can make early diagnosis programs available: Population management will offer rheumatologists opportunities to diagnose inflammatory illnesses sooner, using low-cost screening and ultrasound diagnostic tools. These have been developed and studied.
9. Have ultrasound & technology savvy: Ultrasound could become the rheumatologist’s stethoscope, used in every patient. It can help identify and direct treatment to inflammatory contributors to carpel tunnel syndrome (peri-tendinitis), shoulder pain (intra-articular vs. bursitis), heel and elbow pain (enthesitis), metatarsalgia (synovitis) and knee pain (Baker’s cyst/effusion). Hip MRIs and fluoroscopy exposure, missed work and treatment delays are frequently avoided when ultrasound diagnosis and guided injections are performed during the scheduled office visit. Ultrasound will facilitate earlier diagnosis of inflammatory arthritis and spondylitis, leading to improved outcomes.²¹
10. Provide patient-centered research and care: Self-management program development and research have been in the purview of rheumatology since Kate Lorig, DrPH, developed and tested the Arthritis Self-Management Program (ASMP) more than 30 years ago. The ASMP has been translated into other languages and promoted by the CDC.²² Population management will incentivize rheumatologists to use this tool, which we too frequently have left on the sideline. If we consider Ed Wagner’s description of an activated patient, I think he raises the bar for all of us. An activated patient a) has insight into the condition and can cope with it; b) makes lifestyle adjustments; c) is committed to following the therapy and/or pharmacotherapy; d) is capable of detecting and interpreting signals from their own body; e) is capable of adjusting medications according to fluctuations during the course of the illness; and f) has meaningful activities during the day.²³ An activated patient may not only manage better, but may also calm their overly activated immune system.

Ultimately, it’s all about the patient. Yes, this seems obvious, but watch out for when we start thinking too hard.²⁴ I recently listened to a physiatrist present a one-hour, 30-slide PowerPoint discussion on musculoskeletal integration and care management for a large hospital system ACO—not once was the word “patient” stated or written. The diversity of providers seeing musculoskeletal conditions makes vertical integration and guideline development more complex than for oncology and cardiovascular illness. This elevates the importance of physicians who understand the most complex pathophysiology and current medical therapies, mechanics and rehabilitation principles, and most of all—who listen closely to the patient’s story, values, desires, self-care activities and emotional needs.