Rheumatologist Rachelle Buchbinder, AO, MBBS (Hons), MSc, PhD, discusses reducing overdiagnosis, overtreatment, low-value care and waste in medicine.
Ethics Forum: Mitigation Tips for Health Disparities Among Rural & Indigenous Peoples
A common case scenario in our practice in North Dakota is a woman with rheumatoid arthritis on methotrexate monotherapy. She is a member of the Sisseton Wahpeton Oyate people and lives 90 miles from our rheumatology clinic. She currently has moderate disease activity, indicating the need for additional treatment. She does not have her own…
Ethics Forum: Thoughts on Managing Electronic Communication with Patients
Recent proposals in the U.S. to bill for electronic communication with our patients could be seen as a refreshing but contested attempt to battle burnout rates in the present era. A fee for electronic communications between patients and clinicians also acknowledges the value of the clinician’s time and expertise. But is this ethical? Discussion Burnout…
In the Wake of Dobbs v. Jackson Women’s Health Organization
Since the Supreme Court ruling in June 2022 overturning 50 years of precedent protecting abortion as a constitutional right (Dobbs v. Jackson Women’s Health Organization), states are enacting and implementing new laws to regulate abortion, and medical organizations and healthcare providers are assuming the large task of understanding what the new laws mean for their…
Conflicts of Interest in Guideline Development: What to Do When Everyone Has a Conflict
Avoiding real and apparent conflicts of interest is a fundamental principle of guideline development, but what should we do when every thought leader is conflicted? An example of this conundrum in rheumatology has been the ACR’s ongoing effort to establish guidelines for the management of lupus nephritis, which has been stymied by the fact that…
Ethics Forum: Has the Patient Asked for More Than Can Be Ethically Allowed?
The patient, a 76-year-old woman, had very active polyarticular rheumatoid arthritis (RA), despite triple therapy with conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs), low-dose corticosteroids and occasional intra-articular injections—the latter providing only transient symptomatic relief. She had elevated inflammatory markers and a 28-joint Disease Activity Score (DAS-28) score of 7.4. Because of the severity of her…
Speak Out Rheum: To Prescribe Is Humane (Unless You’re In Texas)
You are a rheumatologist in Texas. You are very well trained. Your mentors included some of the leaders in rheumatology, and you are respected by your colleagues and your patients. You know the devastation of untreated rheumatoid arthritis and lupus. A young woman with recent onset of systemic lupus erythematosus is your new patient. You…
Where Do Rules End & Compassion Begin?
My long-standing patient with CRST syndrome (i.e., calcinosis cutis, Raynaud’s phenomenon, sclerodactyly and telangiectasia) had been losing ground over the past 18 months. BL was 54 and had developed restrictive pulmonary disease without radiographic pulmonary infiltrates. Her mean right heart pressures were moderately elevated by ultrasonography. But the greatest impact on her quality of life…
Cliff Diving: Evergreening & Other Oddities
The glassblowers were in revolt. The island of Murano, in the 13th century, was a perfect home for the glassblowing industry. Connected to Venice through a system of bridges, Murano was surrounded by waters that protected the city from the furnaces that fueled the glassblowers’ craft. The Republic of Venice dominated trade throughout the Mediterranean,…
Ethics Forum: Billing, Burnout and Protected Non-Clinical Time
It’s 11 a.m. on a Wednesday. You see a new patient in your fellow’s clinic with impressive physical findings, including a prominent skin rash and deforming arthritis. The patient has been to many doctors and is frustrated that her condition remains undiagnosed and untreated. You thoroughly examine the patient, present her case to your attending…
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