Dr. Coblyn notes the length of medical stay has dramatically decreased during his time as a practicing physician. “It was nice to have our patients in for a long time, and we would see them every day. With hip replacements, some patients are discharged the same day now. We used to have people in for almost two weeks for hip replacements. They would come in; they would climb stairs and see therapists and consults. So it’s really so different.”
‘I think this happened from cost pressures & from improved efficiency of care. It has changed because of economics, because of the requirements to get people in & out & because of the shifts in disease severity—especially for rheumatoid arthritis.’ —Dr. Coblyn
Transition Away
Through the 1980s and ’90s, a gradual shift occurred as more and more dedicated rheumatic disease units began to close. Instead, rheumatology patients were admitted to a general medicine service that was given the primary responsibility for the patient’s care. The general medical team would then contact the rheumatology service to see the patient and make their own treatment recommendations from a rheumatological standpoint.
Dr. Coblyn explains, “If it is an actual rheumatic disease, such as vasculitis or severe rheumatoid arthritis or bad lupus, we will see them with our rheum fellow and sometimes house staff and medical students. We will see them every day along with the other care team, usually the hospitalist service. Eventually the medical service evolved into a hospitalist world where none of us attend. We consult, but we don’t attend on the day-to-day care of our patients.” Dr. Coblyn also notes the patients they see now through the inpatient rheum service are usually much sicker. “It’s rarely rheumatoid arthritis unless they are having infection or some terrible complication. And the inpatient service volume is so much less because of that.”
In part, this shift occurred due to the availability of much better treatments. During the early part of the 20th century, physicians had access only to symptomatic treatments for rheumatic diseases, such as salicylates and physical therapy. The discovery of the effectiveness of corticosteroids in the 1940s was followed by other new agents: parenteral gold salts, sulfasalazine, chloroquine, hydroxychloroquine, cyclosporine, azathioprine and, eventually, methotrexate in 1988. In the late 1990s, the first biologic drugs became available, further revolutionizing disease treatment.4
Of course, many patients with rheumatic disease still require hospitalization, even if their rheumatic disease is not the primary reason. Patients with rheumatic disease are more likely to have heart attacks, strokes, kidney disease and other systemic issues. Rheumatic patients are much less likely to be seen for advanced, untreated disease than they were in the past. Still, serious sequelae of these diseases do sometimes occur, whether related to the disease process itself or secondary to medication side effects.5 The consult model ensures rheumatologists can still provide input on these patients when needed, as well as contribute their insights when patient diagnosis is uncertain.
