PMR and Telemedicine: do we really need an office visit? Save

Polymyalgia rheumatica (PMR) is a clinical diagnosis; the importance of a detailed history and clinical exam cannot be emphasized enough.  PMR is a common diagnosis that we see in rheumatology but is also seen, especially initially, by our colleagues in primary care.  When we are considering a diagnosis of PMR, it is key to evaluate the patient accurately and efficiently. Can we use a synchronous audiovisual visit or a rheumatology eConsult to evaluate the patient's symptoms quickly? Does it allow us to make an accurate diagnosis? 

I would argue that for most of these cases we indeed can. 

The patient's history and most of the clinical exam can be obtained virtually. We need to employ one of the skills that we do best: listening to the patient. Most patients that have symptoms suggestive of PMR will “tell” us the diagnosis. A patient can explain their symptoms of aching pain and stiffness, centered around their shoulder and hip girdles. Many patients will notice a change from any prior chronic pain they may have in these areas. Patients can explain that their activities of daily living are impacted greatly, and they tend to notice the not-so-subtle change in overall function. Patients can have laboratory testing completed, including ESR, CRP, CBC, and CMP (RF and CCP if indicated), in a timely manner. Patients commonly will have an antecedent synchronous audiovisual visit or an office visit with their PCP for their symptoms before a rheumatology evaluation is even mentioned. Rheumatology eConsults (asynchronous provider-to-provider patient case review with timely recommendations) can be quite helpful in this scenario and can serve as an option to fast-track patients.  

Waiting times to see a rheumatologist are long. Can we improve waiting times if we are concerned about a diagnosis of PMR, especially with severe symptoms, by using home audiovisual visits and rheumatology eConsults? Yes, we can! This requires an alliance with our primary care colleagues.  I would make a case that a relationship with our primary care colleagues for the diagnosis of PMR is critical.  

We know how to ask the right questions. We need to get back to the fundamental principle of obtaining a good history and clinical exam; this can be done using telemedicine for most cases. We need to be comfortable treating for likely PMR if there is enough there in terms of symptoms and supportive laboratory results. Results of needed laboratory testing do not take long to return.  We can evaluate for any red flag symptoms when talking with the patient. Of utmost importance is to make sure there is no suspicion for giant cell arteritis (GCA), infection, or malignancy. Asking about a new headache, describing jaw claudication, describing scalp tenderness, and asking about new visual changes can all be done virtually. Patients have the ability to take vital signs at home. We can ask about symptoms involving peripheral joints. Patients can show us their wrists, hands, and feet. You can ask the patient to perform joint range of motion. 

The COVID-19 pandemic thrusted telemedicine into the spotlight. However, we were accelerating to increased telemedicine use without the COVID-19 pandemic. Some patients are homebound. Patients have issues with transportation, concerns about infection risk when presenting to clinic for evaluation, and struggle with changes in weather that hinder their ability to be there in person. All these factors support providing virtual care; otherwise, there may not be ANY care. We need to follow patients closely and evaluate their response to treatment.  The right care for the right patient at the right time in the best way.

I think about these two quotes often in my daily practice: 

“If you listen to patients carefully enough, they will tell you the diagnosis.”  -- Sir William Osler

“There is only one cardinal rule: One must always listen to the patient.”  -- Oliver Sacks

In my opinion, using synchronous audiovisual visits or rheumatology eConsults to evaluate patients more quickly and efficiently with symptoms of PMR is a very practical and timely approach. Remember PMR: Patient’s history, appropriate Means to obtain the history and clinical exam, and monitor the patient’s Response.