Rheumatology in a COVID & Post-COVID World

Jane’s* hands and wrists had been swollen and painful for about eight weeks. Lab findings in the ambulatory consult that came to our office revealed a cyclic citrullinated peptide antibody count >250 u/mL. We all know where this story goes, including how important the early treatment window is.

Chris Phillips, MD

Our clinic reviews all consults and tries to expedite those with findings such as these. A certain virus affected our plans this time, though. Due to the COVID-19 pandemic, an executive order in our state allows us to see only urgent and emergent cases in clinic. Although Jane may qualify, a second catch was her report that the chicken plant where she worked had recently seen several COVID cases. So our first meeting occurred with the help of a high-speed internet connection.

Because Jane’s astute referring physician had obtained all the necessary labs and because our audiovisual connection allowed me to see the synovitis in her hands clearly, I promptly started her on disease-modifying anti-rheumatic drug (DMARD) therapy. Our next visit may also be virtual, depending on how the pandemic progresses.

As I disconnected, it struck me that several months ago, telehealth a) sounded like something that would only be useful in central Montana and b) would require too much in start-up cost and technical know-how with too little opportunity for reimbursement. Several months ago, COVID-19 also sounded like a good name for the NASA Mars project.

Acute Practice Impacts
Times are changing rapidly. The negative economic effects of the COVID-19 pandemic on rheumatology practices have been well documented.^1,2 For many of us, the day-to-day operation of our practices scarcely resembles what it looked like just a few months ago. My pre-COVID practice comprised five or six new patients and 20–22 established patients per day, and 14–18 established patients per day for my physician assistant.

As our patients began to recognize the reality of the crisis, but before we optimized telehealth, I nadired at three visits in one day. Currently, using doxy.me (and FaceTime as a backup), I am seeing 10–14 telehealth patients per day and between two and eight urgent, in-person patient visits per day.

Different parts of the country have had different impacts. From western Kentucky, I cannot pretend to comprehend the life of a New York rheumatologist. Employed and academic rheumatologists face salary reductions, while independent rheumatologists worry about having to close their practices if the crisis continues. What can we learn from this crisis, how can we survive it, and where will the dust settle when it’s over?