Camelot allegedly existed once upon a time in South Wales. The name was evoked again in the 1960s, but perhaps it is also applicable to the character of rheumatology in the halcyon days of the 1970s and 80s.
That’s not to belittle the world we now live in, with so many treatment options for our patients. However, something seems to have been lost in a half century. Rheumatology was predicated on the basics. Those included: 1) development of an encyclopedic knowledge of musculoskeletal and multisystem diseases; 2) assessment of patients utilizing a full history and physical; 3) vetted examination techniques specific to the specialty (e.g., the rheumatologic musculoskeletal examination); 4) development of pertinent laboratory tests and recognition of their value and limitations; and 5) utilization of radiologic studies (rather than depending upon reports) and their interpretation to confirm clinical impressions.
Super-Internists
The rheumatologist at that time could be considered a super-internist, having all the skills of internists, but also an encyclopedic knowledge and experience base to be able to pull together disparate, apparently unconnected information to make diagnoses and improve the quality of life of our patients. Our history taking was more encompassing, as was our physical examination. We would not think of taking on the care of a patient without having personally extracted the historical information and without personally performing a complete physical examination.
Accepting diagnoses from any source outside one’s own assessment was unacceptable. We checked the basis for past diagnoses and how (or if) they were verified. This is exemplified by a patient I saw who claimed a diagnosis of Ehlers-Danlos syndrome was confirmed by prior physicians, but whose joint extensibility findings and polymerase chain reaction–DNA studies did not meet the criteria for that syndrome.
Such recognition of erroneous diagnoses or inappropriate therapeutic interventions is not always appreciated by patients, whether because of personal benefits provided by having a given diagnosis or because some other physician or the internet provided that diagnosis or approach.
Inadequate provision of time and support staff by healthcare corporations to ensure patient understanding and comfort with the new validated information is reflected in lower patient satisfaction scores. In the corporate view, patient satisfaction trumps validity, quality and safety. Because patient satisfaction is used in determining reimbursement levels, it is an important metric.
Rather than providing a mechanism with documented efficacy in patient communication (e.g., reinforcement of patient visit discussions), healthcare corporations seem to place income over people. Perhaps the downgrading of rheumatology practice in such environments is the response to such pressures; it is easier for the physician to simply accept previous diagnoses, perform minimal examinations and acquiesce to patient whims. After all, anything else takes time.
