Summer 2016 (Volume 26, Number 2)

E-Rheumatology

By Philip A. Baer, MDCM, FRCPC, FACR

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Work-life balance is elusive and requires boundaries to be established and safeguarded. Learning to say no was a key skill I was not taught in medical school or residency, but found important to acquire once I was my own boss in practice. I dabbled in everything from Phase 2/3 research to medico-legal work to on-call duties in internal medicine—at first. Over time, I distilled my work down to clinical rheumatology, medical education, and medical politics, a far more manageable blend. Even the boundaries of inflammatory arthritis (IA) and connective tissue disease (CTD), but will see patients with osteoporosis, osteoarthritis (OA), and regional rheumatic conditions. Many of my colleagues, even in community settings, will not.

The arrival of electronic medical records (EMRs) posed a new threat. Now I can access my office from home, meetings, or even vacation settings. On the one hand, abnormal lab results and prescription renewals are handled in far more timely fashion. Returning to the office from a few weeks away no longer means facing a mountain of paper referrals and test reports. However, is it truly a vacation if you are checking in at the office daily?

The next challenge is looming: The e-consult. Ontario is piloting a setup where primary-care physicians can request advice through this route, sending a question and supporting patient data to a consultant. Both sides are paid for the service. Apparently, the pilot is quite a success, with 30% of interactions handled solely by e-consult, obviating the need for a face-to-face consultation.

I have not yet signed up. For-profit services have approached me to enlist, promising to handle everything through the required secure e-mail server, and funnelling e-consult requests to me if I let them take a cut of the fees. The thought of further encroaching on my evening and weekend free time is not appealing.

On the other hand, pro bono rheumatology e-consults are different. Being surrounded by physicians in my family and my professional life, it is sometimes hard to remember that many people do not number a doctor among their personal acquaintances, or perhaps only one. Working at insurance company head offices where I am the only physician leads to frequent requests to review coworkers’ test results or provide advice. Of course, I am careful to provide general advice only, as these are not full clinical interactions, and often deal with aspects of medicine outside of rheumatology. The Canadian Medical Protective Association (CMPA) urges caution in this field, and I agree. As well, the regulatory College in Ontario frowns on treating or providing advice to family members and close friends, so those requests have to be tactfully redirected as well.

Social media has enlarged the circle of advice seekers. In the middle of a busy office recently, LinkedIn signalled I had a message from a familiar name, albeit someone I had last worked with years ago. The message concerned an elderly parent with spinal stenosis and chronic pain, inadequately relieved after visiting a surgeon and a pain clinic. What could I recommend? Well, I had a few ideas. I did not volunteer to see the patient, but my response received what seemed to be heartfelt thanks, which I found more gratifying than being paid a trivial amount for an e-consult. I also now know what work the advice seeker is currently performing, and perhaps we will renew our social acquaintance as a result.

Far more difficult was a recent request forwarded to me by one of our sons, regarding a former classmate, now in her mid-20s: “As you know, my back started hurting in high school when I was 17. I've had chronic pain ever since that gets better and worse at times. What helps the most is moving, and staying in any single position for a while is difficult. What's been more concerning is the progression of pain in my upper body in the last year or so. I've tried chiropractic, acupuncture, physical therapy (that doctor only saw me once and gave me two exercises and said there wasn't anything he could do).”

Well, I thought I knew what this was: Inflammatory back pain.

I read further: “My father and some of his siblings have psoriatic arthritis, my sister was recently told she had an arthritic spine (which left her stuck in bed for a few weeks), and then there's me. Also, my niece, who is four, recently had surgery on her hip. It was very sudden, because they found inflammation, and out of fear of septic arthritis from a bacterial infection, they operated on her. ”

Ah ha! Seronegative spondyloarthropathy, surely.

“I don't know if I should pursue this any further with doctors? I keep getting told things like, ‘you're too young for back pain’. I'm at a point where trying to fold laundry or do dishes for more than 10 minutes can cause so much pain that I can't continue. I also have a lot of random pain which seems to ‘move around’ in my left knee, hip, and ankle, which will suddenly make it difficult to go up and down stairs. For about two weeks, I was leaving for work around 6:30am to avoid traffic because I wasn't able to sit in the car during normal rush hour without being in pain.”

I could not resist getting involved. I wrote back saying “You almost certainly have axial spondyloarthritis (SpA). It fits with your pain description, family history, etc. Typical delay in diagnosis is five to seven years, more in women. You need to see a rheumatologist.”

Denouement? She tested positive for HLA-B27, saw a rheumatologist, had an MRI of the sacroiliac (SI) joints which was negative, and was told she did not have SpA.

Now what? I have not examined her. I do not know if the MRI was properly read. Perhaps it is truly negative, but an MRI of the whole spine might show something (said to be true in 15% of cases). Nonsteroidal anti-inflammatory drugs (NSAIDs) apparently did not help.

I am still struggling with what to do, but the slippery slope of e-rheumatology is much clearer to me now.

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