Summer 2014 (Volume 24, Number 2)

My Way

By Philip A. Baer, MDCM, FRCPC, FACR

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“I planned each charted course; each careful step along the byway,
But more, much more than this, I did it my way.”

— Frank Sinatra, “My Way” (lyrics, Paul Anka; composers, Claude François & Jacques Revaux), My Way, 1969.

The patient’s journey with a chronic disease like arthritis has the structure of any story – a beginning, a middle portion, and an end. I find the best outcomes and most satisfying patient encounters occur when the patient’s beginning occurs under my care, as opposed to someone else’s. I am never as sure about what to do for an inherited patient as I am for someone whom I followed from their first interaction with a rheumatologist. Examples:

A patient comes with established rheumatoid arthritis (RA) on low-dose steroids and methotrexate (MTX). I know I screen everyone before MTX use for hepatitis B and C status and carry out a baseline chest X-ray. Did the previous rheumatologist do that? Does the patient recall being screened? Do I have to carry out these tests for someone on MTX for
10 years who cannot recall what was done at MTX initiation?

Could someone please standardize folic acid supplementation for MTX? I have my routine: MTX every Saturday, folic acid 5 mg on weekdays. The origin of this routine is shrouded in the mists of history, but it works for me. Inherited patients recently have arrived on the following regimens: Folic acid 1 mg or 5 mg, taken three, six, or seven days a week; folic acid
10 mg taken one or two days after the weekly MTX dose; and others. Lab work for MTX monitoring might have been ordered every four, six, eight, or 12 weeks. I ask for blood work every six weeks and, with many patients, I am lucky to receive test results every eight to 12 weeks.

An inherited RA patient calls because of a flare-up. They demand an intra-muscular (IM) injection of steroid, as done once or twice per year by their previous rheumatologist. Well, I have not given such an injection in more than 25 years of practice. I prefer injecting one or two swollen joints instead, or giving a short course of tapering oral steroids (no refills, mind you). How to explain to a patient who is convinced they need an IM injection?

Another patient I inherited had psoriatic arthritis (PsA). I received a fax from a pharmacy requesting a refill of a topical steroid medication for the treatment of his psoriasis. I sent it back with a note indicating I had not prescribed this medication, and that it should be obtained from the prior prescriber, either the treating family physician or dermatologist. Unbeknownst to me, the patient’s prior rheumatologist had been in the practice of prescribing the patient’s topical steroids, something I never do. Next thing I knew, the patient was berating my relatively new secretary about his missing refill, apparently perceived to be of life-saving importance. A College complaint was threatened, though never proceeded with. This led to a call to the Canadian Medical Protective Association (CMPA) and intensive chart documentation by me and by my secretary.

I suppose if we all did things the same way, it could be considered boring and a cookie-cutter approach to medical care. But, it certainly would be a lot simpler!

And so, as Friedrich Nietzsche said, “you have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist.”

Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario