Winter 2020 (Volume 30, Number 4)
Core and Explore:
A Sequel to What is a Rheumatologist?1
By Philip A. Baer, MDCM, FRCPC, FACR
"What's past is prologue."
– The Tempest by William Shakespeare
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How do past patterns of rheumatology practice affect
the rheumatologists of today?
At a recent large primary care continuing medical
education (CME) event, I was mingling with attendees
after presenting a review on osteoporosis. A stranger approached
proffering his business card and started discussing
his research/business venture in the field of fibromyalgia
(FM). What was “the ask”: Could I please review the
protocol and business plan and provide advice? I replied
that, while I was flattered to be considered, fibromyalgia
was no longer a core interest of rheumatologists, including
myself. I referred him to the websites of the CRA and Canadian
Pain Society to find someone more suitable.
That started me thinking about the evolution of rheumatology
as a discipline. At the core, everyone agrees on
the primacy of the inflammatory arthritides and the poorly
named “connective tissue diseases.” However, while gout is
the most common inflammatory arthritis, particularly in
men, it is clearly not part of the holy trinity of rheumatoid
arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis
(axial SpA).
Osteoporosis (OP) as a primary diagnosis is treated only
by a minority of rheumatologists. Low back pain is an orphan
but ubiquitous condition. Orthopedists and neurosurgeons
certainly don’t want to see unselected patients
with this condition, nor do rheumatologists. Could this
explain the relative absence of ankylosing spondylitis (AS)
patients in my practice (prevalence 0.5-1% of the general
population, similar to RA, but underrepresented in my
practice versus RA by a factor of 5:1), as well as the commonly
cited delay in AS diagnosis of five-to-nine years? In
Ontario, we are expanding Inter-professional Spine Assessment
and Education Clinic (ISAEC) sites to attempt to deal
better with low back pain sufferers.2 European attempts to
enrich the likelihood of finding inflammatory back pain patients
among the masses of chronic low back pain patients
under age 45 also come to mind.
Some rheumatologists are happy to see simple conditions
such as tendinitis, bursitis, rotator cuff syndrome, epicondylitis
and trigger finger. Others have no time for anything
but our core conditions. “These conditions should
be managed in primary care” is the refrain. The issue, of
course, is the limited training most primary care practitioners
have in musculoskeletal (MSK) conditions such as
these, as well as osteoporosis and gout, which should also
ideally be handled in their offices. The limited availability
of physiatrists, and their focus on complex rehabilitation
and trauma/neurologic conditions, also leads to these patients
being referred to rheumatologists.
Having dispensed with spinal osteoarthritis (OA) and
degenerative disc disease (DDD), what about peripheral
OA of the hands, hips and knees? After all, the American
College of Rheumatology (ACR) and European League
Against Rheumatism (EULAR) continue to produce guidelines
on this topic, most recently the draft ACR/Arthritis
Foundation guidelines presented at ACR 2019. This is the
most common arthritis of all, but is it core to any discipline,
let alone rheumatology? Tom Appleton and Gillian Hawker
are prominent Canadian researchers focused on OA, but
my peers certainly aren’t. At the two journal clubs which
I regularly attend, I can’t remember the last time anyone
chose to present an article about OA. Vasculitis as a topic
is far overrepresented at these events, in contrast to its
low prevalence. Should every patient with hip/knee OA see
a rheumatologist before being directed to an orthopedic
surgeon, to ensure medical management has been fully exhausted
before total joint replacement? Impossible in the
current Canadian context. Again, Ontario is experimenting
with central assessment of such patients at dedicated Rapid
Access Clinics, with triage by trained physiotherapists
or nurse practitioners as the initial step.3 Likely, these approaches
are in existence or being considered elsewhere in
our balkanized Canadian healthcare system.
Artie Kavanaugh made a telling comment at the ACR
2019 Rheumatology Roundup session covering the highlights
of the meeting. While he did not note the draft guidelines
on OA and gout presented there, he did comment
on the presence of fibromyalgia research at the meeting, including posters and concurrent sessions, as well as the
guidelines on FM promulgated by various rheumatology organizations
(including the CRA). Perhaps tongue-in-cheek,
he opined that if rheumatologists do not want to be considered
as experts in FM care, maybe such research should not
be part of our meetings. Of course, if we don’t create these
guidelines, who will? The intended audience are the primary
care practitioners to whom we want to offload gout, OA,
FM and osteoporosis, not rheumatologists.
Can we learn a lesson from the legendary Warren Buffett
to help resolve these dilemmas? As do many investment
gurus, he advocates that non-professional investors should
“buy the market” by buying and holding broad stock and
bond index exchange-traded funds (ETFs) at low cost: the
core. At the same time, all investment companies recognize
the desire of retail investors to hit a home run, rather
than accept plodding returns compounded over decades.
Hence, “core and explore”: Put 80-90% of your money in
the core ETFs, and use 10-20% as “mad money” to find the
next Apple, Alphabet or Amazon, while staying away from
the crashing cannabis sector, Uber/Lyft, and others not for
the faint of heart.
You are probably wondering what any of this financial
information has to do with rheumatology? Well, we can
practice “core and explore” in two ways. First, we can educate
our non-rheumatology colleagues and the general
public that the core of rheumatology has shifted. While we
may have previously accepted referrals on anything within
the broad field of MSK medicine, we have now refined
our core to the immune-mediated inflammatory arthritides,
and whatever we choose to call “collagen-vascular
diseases.” Gout, peripheral OA and osteoporosis may be in
the outer reaches of the core for many of us, but chronic
pain, FM, non-inflammatory spinal conditions and regional
soft-tissue conditions clearly are not.
Secondly, we can maintain practice variety and our competence
in these common conditions which now lie at the
fringes of rheumatology, but which our patients with the
core conditions frequently complain of secondarily. We can
choose to explore these conditions by accepting selected
patients for one-to-two visits to confirm diagnoses, provide
treatment plans and perhaps provide intra-articular therapies,
for which we are the acknowledged experts.
Comments, kudos and criticism on this topic are welcome
next time you see me.
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario
References:
1. Baer PA. What is a Rheumatologist? CRAJ. Winter 2019. Available at www.craj.ca/archives/2019/English/Winter/Editorial.php
2. Interprofessional Spine Assessment and Education Clinics. Available at www.isaec.org/.
3. Rapid Access Clinics for Musculoskeletal Care. Available at www.hqontario.ca/QualityImprovement/Quality-Improvement-in-Action/Rapid-Access-Clinics-for-Musculoskeletal-Care.
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