Summer 2022 (Volume 32, Number 2)

Overheard at the Office

By Philip A. Baer, MDCM, FRCPC, FACR

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“Ooh I heard it through the grapevine
And I'm just about to lose my mind.”
– from “I heard it through the grapevine” by Marvin Gaye

I run a small solo office practice with just my secretary, me, and our patients physically present. From my own inner office, in between patients, it is not uncommon for me to pick up snippets of my secretary’s conversations on the phone. While not hearing both sides does put me at a disadvantage, I sometimes can’t help wondering what in the world is going on. Some recent examples are below:

The PMR Lab Test
A patient called the office. The patient has PMR1 and had a lab form from me for blood tests every 8 weeks monitoring CBC2, ESR3 and CRP4. In the box labelled “clinical details (e.g., diagnosis)”, I had used my lab form template listing “PMR”, and on the line below “Repeat every 8 weeks.” This has never been an issue on any of my lab requisitions created in the last decade, since I started using an EMR5. However, it apparently mystified the lab, as the patient reported that the lab employees had spent a long time looking through their manual of tests, where they could not find a test called “PMR”! My secretary sorted that out, but this might explain why the occasional lab has delivered serial RF6 testing which I never ordered, likely based on the abbreviation “RA”7 appearing in the same “clinical details” box.

The Eye Doctor
Another patient calls. She has had RA for 10 years, quite mild, and is on hydroxychloroquine (HCQ) with annual eye checkups for monitoring. In Ontario, being in the 18-64-year-old age group, she would not normally receive free eye care. However, I had completed the required form to have these examinations covered, which contains a box in which I must put the reason the patient qualifies. My template form states “On HCQ for [blank space] – requires annual eye monitoring.” The blank is invariably filled in with either RA or SLE8 as the diagnosis. The patient said the eye specialist wanted to know why she is on HCQ! This was bad for two reasons: the consultant evidently hadn’t read the form (so were they doing the correct testing?), and my long-time patient doesn’t seem to have absorbed what her rheumatologic diagnosis is.

The Lab Report
My secretary picks up the daily mail and returns with a paper lab report on one of our patients. This is from a major lab, which normally sends all my lab results electronically directly into my EMR. Rather curious that I would be getting a paper version, I find that it duplicates what I already have received digitally. It also tells me that the copy of the results I had requested to be forwarded to the patient’s family physician could not be sent, as that doctor could not be identified based on the information I had provided. Interesting. I retrieved the electronic copy of the lab requisition and looked at the box specifying where copies were to be sent. That included the following information on the family doctor: first and last name, complete address, fax number and provincial billing number! I might add that the last name was a lot less common than Smith, Singh or Wong are in my community, so the information was perfectly adequate to identify one and only one physician. I had my secretary call the lab, both to put a stop to randomly getting unwanted paper reports, and to find out what more they needed to route copies of the results to the general practitioner (GP). The answer made no sense: they had recently upgraded their system, and now the GP was identifiable. I hope that’s true.

No wonder the prevalence of physician burnout is on the rise. There isn’t enough time in the day to deal with all these niggling issues. However, occasionally a recurring problem meets a pre-designed solution, giving me hope for a better future.

The Fourth COVID-19 Vaccine Dose
My patient on an advanced therapy for RA is seen in follow-up in the morning, having had three vaccine doses. As I tell every patient in this position, he qualifies for a fourth dose twelve weeks after receiving his third dose (that is the current rule in Ontario, at the time of this writing). Based on intensive work done by the ORA9, led by Dr. Jane Purvis, we have established that patients do not require a letter from their rheumatologist to access this fourth dose. They just need to show their medication bottle or their prescription list at the vaccination site. That position has been endorsed by our provincial Ministry of Health and the leadership of our major retail pharmacy companies. The patient says he is planning to get his vaccine at his local pharmacy which also supplies his RA medications. Great — there should be no problems.

The same afternoon, I hear my secretary talking to the same patient. His pharmacy, a store in a major chain, wants a letter from me before they will give him his shot. Well, I have a template for such letters, so I fax it over to the pharmacy so the patient will get what he needs. But I don’t stop there: I also fax them the ORA one-pager on the correct fourth dose implementation protocol. And I contact Dr. Purvis and our ORA Executive Director with the pharmacy name and store number, address, telephone and fax numbers. Within the hour, I am assured that the relevant people at the Ministry of Health and at the pharmacy chain head office have been notified. Maybe that will help other patients and other rheumatologists avoid being faced with these situations. A small victory, but we need those occasionally to keep fighting the good fight on behalf of our patients.

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


1. PMR: Polymyalgia rheumatica
2. CBC: Complete blood count
3. ESR: Erythrocyte sedimentation rate
4. CRP: C-reactive protein
5. EMR: Electronic medical record
6. RF: Rheumatoid factor
7. RA: Rheumatoid arthritis
8. SLE: Systemic lupus erythematosus
9. ORA: Ontario Rheumatology Association


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