Monday, 20 Jan 2020

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Building a Better Rheumatologist

There’s a certain comfort to work that is rote, mechanistic and almost automatic. The mailman sorts his mail, delivers that mail to a well-planned route, and then circles back to collect and redirect outgoing new mail. Tuesdays schedule and tasks are the same as those done on September 14th. Aside from variances afforded by weather, interruptions (the loose rabid escaped zoo animal) or personal illness, you’re just “workin', slavin', every day”. Workloads may be increasing, but you cope by complaint, resistance or innovation.

These repetitive algorithms have certain advantages: 1) they’re comforting in their efficiency; 2) comprehensive patterns ensures high quality care; 3) following the script, makes it highly unlikely that something will be missed or that a mistake will be made; and 4) by these actions you’ll be meeting expectations of many - patients, coworkers, those “in charge”, and yourself.

Yet it makes no sense to treat everyone the same. Not everyone needs or wants a full-course meal or needs a full 99245 visit. Doing more rote work could be profitable, but it could also be wasteful and costly. Conversely if you do less, will it be at the expense of quality, satisfaction or income? No one wants to be labeled the “short-cut” doc.” But what if you changed the way your work? Might you become “the most interesting MD in rheumatology”?

It’s important to note that even if the rheumatologist is repetitive in task and predictable in function, most rheumatologists bring concern and intellect to each patient encounter. As noted previously (see “the Favored Few”), high science and quality relationships are the motivating forces behind the practicing rheumatologist. Nevertheless, the automaton is alive and working in rheumatology as we daily care for patients. Whether you’re a solo, group or multispecialty group practitioner, pediatric rheumatologist, academic or VA rheumatologist you do what you do the same way day in and day out.

Unmet Needs. There are 57 million people with arthritis and while our population ages, our rheumatology workforce is in decline. Hence, the increasing demands for your diagnostic acumen and therapeutic expertise with strain you or change you. Estimates are that we currently care for less than 3% of all gout patients, less than half of all RA and lupus, a much smaller percentage of all PsA, AS and SpA patients. Coupled with staggering numbers of osteoarthritis (27 million) and fibromyalgia (5+ million) patients, the declining numbers of rheumatology practitioners are left to deal with an exponential demand for their services – which will be met by either: complaining, resisting or innovating the way in which they work.

Few practicing rheumatologists have gone rogue and become “concierge” or cash only (pay by contract or by the minute) or who are solely dedicated to one disease (e.g., the “lupologist”). We can extol, excommunicate, vilify or write about them; but we cannot rely on them to address of fix the problems of future care that will face rheumatologists in the years to come.

If your only objective and desire is to keep your schedule full and maximize your reimbursements, then you can stop reading here, because the remaining paragraphs are about redesigning what you do to build “a better rheumatologist”. Does this mean you should quicken your visits or lengthen your return evaluations? A “better you” could read more, become bilingual and wear roller-skates around the office. Or you could learn to work smarter (not harder), with greater operational efficiency and clarify your goals for patient care.

Practice Redesign. Dr. Eric Newman has written a wonderful article in Arthritis & Rheumatism in 2004 called, “The rheumatologist can see you now". Successful implementation of an advanced access model in a rheumatology practice”. He outlines an intelligent and alternative way of reducing wait times by eliminate backlog, creating access time for same-day patients, retooling the appointments process and establishing protocols for referring doctors. Hopefully, no one these days measures their worth or popularity in how long it takes to get a new patient appointment with you. If your “wait list” time is over 4 weeks, you have unknowingly influenced you potential intake population. With such a wait, it’s more likely you will see degenerative and fibromyalgia patients, since anyone with an acute, inflammatory or autoimmune disorder are going to find expedient consultation elsewhere.

Information Management. Nearly all of us either use an electronic medical record or in the least maintain charted problem lists, medication and allergy lists. Everyone should invest in automating and maintaining such requisite information by either 1) using pre-visit screening forms (New Pt Survey and FUV Survey forms can be downloaded); 2) use EMR patient portals to upload and maintain accurate lists of diagnoses, surgeries, medications, hospitalizations; and 3) hire a medical assistant (MA) to collect and maintain such lists and ready the patient for your involvement in each encounter. An MA salary can range from $20,000 to $30,000 per year. If you see 2880 patients a year (15 per day, 4 days per week) and if you spend 10 minutes collecting and updating such information the cost to you is $96,000 per hear for 480 hours of your effort ($200/hr) that can be done by the MA for $25,000 per annum. Moreover the MA will only spend half to two-thirds of her work week on this task alone and can be utilized for phone calls, preapprovals and refill requests.

Appointments. The patients who need and want to see you this week are the ones you should be aching and working to see. What does your practice do to facilitate expedient and facile scheduling? I believe it’s a mistake to mix new patient and follow-up appointments in the same day or half-day - there are too many differences amongst this mix to reasonably and reliably utilize your time. New patients can be allocated to specific half-days, the beginning or end of every visit or even a novel time slot. Several of my colleagues will see new patient appointments on Saturday morning. I have a Monday night new patient clinic (most weeks) that will see as many as will call. If 3 call, they can get fairly extensive evaluations; but if 7 show up - the goals and process is different, focusing on data collection, the primary complaint and immediate evaluation, testing or treatment.

Some advocate for chart screening prior to appointment. I’m not a big fan of chart reviews as a means of officiating the appropriateness of consultation. It’s restrictive and elitist to presume you can judge or prediagnose based on your interest or the writings and testing of those with limited MSK skills. I understand the rationale (I too am very much against wasting my limited time), but I believe the effort of saying what you won’t see or do is better spent on advertising and networking with your peers on which patients need to be referred and what diseases you are most interested in.

New Consultations. The usual New Patient Consultation is sequential and includes the Chief complaint, HPI, Past medical history, medication review, allergies, Social and Family histories, Review of Systems, Vital signs, Medical exam, Rheumatologic exam, specialty system exam (e.g., ENT or neurologic), Assessment & Diagnosis, Plan for follow-up care/visits, testing, referrals, imaging, counseling, etc. 

The above evaluation assumes you know nothing about the patient’s problem or diagnosis before stepping into the exam room. This may have been true in my first clinic encounter after completing fellowship. But since, then I’ve realized that: 1) common conditions occur commonly; 2) consultations accompanied by labs or x-ray results are easier than those without or those with physician evaluation notes only; 3) skillful pattern recognition is vitally important in the best practice of medicine; 4) it may not be wise for me to spend 60 minutes, 10 years of education and 30 years of practice on making a diagnosis that if my clinic clerk can correctly guestimate over the phone; and 5) the goal is to acutely diagnose and treat red flag conditions (e.g. septic arthritis, gout, serious infection) and let time and serial evaluations/treatment establish the correct and accurate diagnosis in most.

Could you imagine your approach to a new patient being different, if upon hearing the chief complaint and asking 2-3 questions, you did: A) the joint examination first; or B) did laboratory testing before doing a complete H&P; or C) tried to match the visit speed and accuracy of our hummingbird dermatology colleagues?

I believe that there are 8 types of new outpatient consultations and 7 of these can be turned into 30 minute visits that allow for more face time, education time, more patients seen, etc.

  1. The Acute Urgent Mess: easily spotted; these are patients that should be hospitalized and become inpatient consultations - call the ambulance, PCP or next of kin.
  2. Red Flag Consultations: these are those few conditions when an expedient diagnosis and treatment substantially reduces morbid and mortal risks to the patient. Examples include most patients with a measured documented fever >102F (septic, gout, vasculitis, very aggressive lupus) or an acute monarticular/focal painful joint or limb (fracture, gout, pseudogout, septic arthritis).
  3. Transfer of Care: Such patients are about documentation, information gathering and identifying therapy problems. If the patient has a known diagnosis, especially if seen previously by a card-carrying rheumatologist, then they should only be seen if they or you have their medical records. Unfortunately, >80% of such consults come without records. Time is wasted with guessing past events and patients are surprised that their medical information was never sent ahead of the visit. With records in hand, the MA can help enter and manage information and your remaining visit tasks are limited to confirming and discussing past diagnoses and new suspicions, transferring medication responsibilities and establishing your rules of care as you establish a relationship with the that patient.
    • Cardinal Rules on Transfer patients: A) Never doubt another physician’s diagnosis or treatment, certainly not in the first few visits. Maybe and only when you have all the evidence and several serial evaluations and examinations under your care; B) Never assume another Rheumatologists diagnosis or treatments are correct – ultimately you are responsible for evidence, diagnosis and plan; C) Labs do not diagnoses patients - Rheumatologists do (meaning you’ll have to review and establish the importance and use of labs in your practice); D) It’s Not your Job to explain the past (what others did, diagnosed or said) - you only need to note it and use such information going forward.
  4. Fibromyalgia/Myofascial Pain and Sleep Related MSK complaints; these are easy to spot and can be efficiently evaluated and counseled. The majority of these patients come disguised with erroneous complaints that can vary from suspected RA or lupus, focal or widespread MSK pains, spinal pains -- the central underpinnings are usually evident - problems with sleep, moderate to severe fatigue (usually a primary complaint), history of anxiety, ADHD, or depression, spinal pain, TMJ pain, irritable bowel syndrome, chronic headaches, unexplained numbness and neurologic complaints or multiple medication allergies. The exam should quickly confirm tender points, soft tissue origins of complaints and the lack of synovitis or true muscle weakness. Counseling can be facilitated using the FM patient education packet (previously written about on this site). Identification of this significant subset can save time, avoid unnecessary testing, facilitate sleep or other referrals and initiation of simple analgesics, and sleep aids and a stretching exercise program (i.e., yoga or pool exercise).
  5. Picture Perfect Presentations: You know the diagnosis as soon as you see the patient – Gout, OA, AS, lupus malar rash, Gottrons papules, etc. In the first 20 seconds you identify one of many high yield, specific MSK or skin manifestations that are readily seen and have such strong predictive value. This includes the CMC1 hypertrophy of OA, the rigid habitus or forward head tilt of ankylosing spondylitis, podagra or monarthritis from crystal disease, the malar rash of lupus, Gottrons papules of dermatomyositis and the sausage digit of psoriatic arthritis. When found in the first minute, it should facilitate and guide the rest of the visit. You already have the meds, PMHx and allergies loaded by the MA. In the first minute you see Podagra or Gottrons papules. You spend the next 2 minutes asking the requisite supportive questions to confirm the diagnosis. The rest of this 30 minute visit can be spent with documentation, education and a new treatment plan.
  6. ANA Positive: If you don’t have a process or algorithm to quickly dispense with the +ANA consult you should. Less frequently will consults for a positive rheumatoid factor be seen but the assessment is the same and simple.
  7. “I don’t know why I’m here”: such patients should not be given appointments unless the consultative question is known or unless the referring doctor sends information that clarifies this issue. I don’t require or like consults referral sheets that must be filled out prior to scheduling (this is akin to a “chart screen”), but if the patient isn’t clear about the reason for referral and there are no notes, you should not take the appointment.
  8. Complex Disorders: These are visits that cannot be done in 30 minutes and you may struggle to complete in less than an hour.These are evident when: A) the patient tells your staff they have a complex, perplexing, undiagnoseable or untreatable condition; b) the patient has been hospitalized more than once in the last 6 months for this problem; c) They want to send or give you notes from more than 3 other consultants or more than 2 hospitals or have a several 3 ring binders with past notes, hospital records, tests, biopsies, etc.; and d) are taking more than 20 medications. These should be spotted by the staff ahead of time and allotted a longer visit or you should plan to do the intake in 2 visits.

Each of these requires the “pre-work” (new patient survey forms, entry of drugs and prior diagnoses) before you see the patient. Once done, you need a template or algorithm to deal with unique visits types, options to change each visit on the fly and the appropriate use of time to establish a diagnosis and plan.

Interval Visits & Monitoring. There are several kinds of follow-up visits (FUV). Some of these can be easily dealt with in less than 15 minutes while others will require more time and resources. Ideally you should establish ways to classify these FUV before the patient is given an appointment:

  1. “Doing great” FUV: These can be self-declared by the FUV patient survey form or nurse interview – but need to be verified by the practitioner. With such patients you have to examine and confirm patient status, provide refills, paperwork and guidance. Imagine you have 2 FUV patients waiting in rooms and a 3rd patient being checked in. Instead of going blindly into the next scheduled encounter, an identified “doing great” visit may only take 10 minutes (and coded as such) and can be done ahead of the flare and joint injection and before the new patient transfer of care visit.
  2. Not-So-Great FUV: These established patients will declare they are “doing fair or poor” and will require more effort and time to get to the bottom of their woes. Let others (MA) do the medication and chart updates so that you can focus on problem solving and management issues.
  3. Post-Hospital Visit; such visits are usually more complex and will take time (likely a 99215 visit).
  4. Urgent Walk-ins and Overbooks: You should have a plan or process for such patients. Each of these visits should have a clearly spelled out objective or task - e.g., here for new rash, new swollen joint, needs a joint injection. These should be 10 minute visits with limited complaints, focal findings and a specific action (lab, joint injection, new prescription, or referral to ER/Hospital/other consultant).
  5. Frequent Callers: Patients who call more than 3 times between visits should be considered for an earlier appointment. Such patients can be given appointments for an urgent/intercurrent issue (Short Overbook appointment) or “Not-So-Great” FUV visit. Phone medicine is never a good practice and staff time can be consumed by frequent calls rooted in either miscommunication, new problems drug side effects or patient anxiety.

Based on a 2012 survey of 500 rheumatologists we spend an average of 20 minutes on a follow-up visit (99214), nearly 41 minutes on a new outpatient consultation (99244) and the average return visit for an RA patient on DMARDs is every 4 months.  We all have limited time constraints with the follow-up visit (FUV). I have conservatively estimated that there is only 3-7 minutes at the end of each visit for communication, questions or urgent new problems. During the FUV you need to 1) answer questions; 2) make treatment changes; 3) educate the patient; 4) communicate risks; and 5) encourage the patient (participation, compliance, adherence, overall health and nutrition). The same fore-thought that can save you 20 minutes per patient with a new patient visit needs to be employed to allow you to meet the complex and increasing demands of a 20 minute FUV. The rheumatologist can free up FUV time by:

  • Pre-work by the MA - medicine changes, allergies, new diagnoses/hospitalizations, surgeries, highlight specific patient needs at the outset (e.g., patient needs FMLA papers, patient unable to sleep with new right shoulder pains, etc.)
  • Algorithms and templates for common tasks - Joint injection/aspiration visits, nonformulary request letters, prescriptions for physical, occupational or pool therapy.
  • Reappoint for nonurgent joint aspirations/injections, trigger finger injections, carpal tunnel injections - usually after a conservative trial of rest, ice, immobilization, splinting, etc.
  • Information sharing: do not engage in dictating letters or faxing your notes to colleagues, most of these are lost or not available when the patient is being seen. I prefer to fax notes on new patients and usually give the referring doctor a heads up text, call or email that a fax is coming. Otherwise, for all patients and all notes I give the patient copies of notes/labs and charge them with dispersing your notes to their PCP’s and other consultants. Patients need to be the expert of themselves and that begins with having an organized copy of their personal medical record. One that can be brought to all medical visits, where information sharing is immediate, certain and up to date.

These are several ways of redesigning work flow and specific tasks to meet the varied needs of patients with MSK complaints. I would not presume to know or project the best way to run your clinic, as I have spent the last 30 years learning how to be smarter and more efficient in what I do.

What practice changes have you employed to improve your work flow and meet the demands for your services. What do you believe will be the biggest challenges for rheumatologists in the future?

The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
Dr. Cush is the Executive Editor of and also Co-Edits the online textbook 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

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