Rheumatologists would agree that treating patients in the real world is much more involved and complicated than the rheumatology fellow curriculum could possibly relay. That’s not a criticism of the curriculum, but rather an acknowledgement that over time, rheumatologists gain the experience and skills necessary to help their patients cope with their concerns.
However, unless a rheumatology fellow also has a rheumatic condition, fellows may lack the skills necessary to treat the whole person who is almost always dramatically more complicated than any text book case study could convey. Until a rheumatologist learns how to help the patient — clinically, emotionally and even financially — they will struggle with treating patients.
The Fellowship World
Clinical and scientific curricula are critical components of rheumatology training. An experienced rheumatologist understands more than just the facts and numbers, they understand the complexities of disease and how these intersect with each patient. Learning about and understanding the interface between science and the patient experience is clearly no easy task given the variety of rheumatic conditions, the likelihood of co-morbidities, diseases that mimic rheumatic conditions, diverse populations and the complexities of the treatment landscape. Education on these issues comes not from a textbook, but from experience and good mentorship.
The Real World Challenge #1: Patient-Centered Care
Patients want their rheumatologist to be specialists in the field, but they also want them to understand their particular day-to-day challenges, including the pharmacological and alternative treatments to fit their lifestyle. Further, physicians need the ability to communicate this information effectively and in a culturally-sensitive manner.
In the real world, while the patients are not medical experts, they should be regarded as the experts in their care. They are the only ones capable of explaining how they feel and they should have the final say in whether the treatment is improving their quality of life. If a certain treatment plan is not meeting their expectations, the fellow needs to work with the patient to discuss the pros and cons of continuing with the treatment plan or to explore a new treatment option. Going right to drugs might be a sound scientific approach, but virtually all patients have an interest in exploring complimentary, adjunct approaches such as diet, exercise, mindfulness and other integrated medicine techniques. Some of these approaches have more evidence than others, but knowing that patients have a deep and real interest in exhausting all avenues of disease management means there’s much more to treatment than a prescription for a drug.
The Real World Challenge #2: Navigating Insurance
Unfortunately, because this is the real world, life gets even more complicated. Healthcare has become a political hotbed and with each election, the rules and regulations change. Having a treatment plan in mind that may work for the patient, doesn’t mean the patient’s insurance will offer appropriate coverage or even at a cost the patient can afford. Helping patients navigate their healthcare plan is a daunting challenge that may require the practice hire an expert who can manage the system for the practice and patient.
Rheumatologists must become adept at helping patients access treatments and deal with related stress. Obstacles, such as increased out-of-pocket expenses and utilization management techniques, are likely to get in the way of what you and your patient agree is the best path forward. Be sensitive to the fact that financial issues, especially out-of-pocket costs, consistently rank number one on the list of reasons why patients aren’t adherent to medications. If the co-pay is very high, they may take matters into their own hands and begin skipping doses or rationing their own care. Clinical trials are predicated on regular adherence to medicine. Skipping doses due to financial reasons haven’t been factored into the drug label, but it should be considered during your consultations and follow-ups.
The Real World Challenge #3: Listening and Interpersonal Relationship Skills
Patients are human. They are the result of their upbringing, their genetics, their emotions, their culture, and their worldview. There can never be a ‘one size fits all’ mentality. At the same time, to avoid getting stuck in the weeds, fellows need to treat patients based on the common understanding of their population. This requires incredible listening and interpersonal relationship skills. Often communication breakdowns directly result from a lack of understanding of one another’s worldview. The decisions patients make reflect their cultural values so being aware of one’s own biases assists the healthcare provider in understanding the background influencers from both the patient and themselves (Hays & Erford, 2014).
The Fellow’s Tool Box
Patients look to their healthcare providers to recommend proper resources for support groups, potential research studies in which to participate (or follow), reputable websites for educational purposes on medications, alternative treatments and healthcare coverage plans.
In conclusion, fellows bring a wealth of knowledge and enthusiasm to their patients. They will become great clinicians as they merge their classroom knowledge with real world experience.
Petersen, J. C. (2007). Why don’t we listen better? Communicating & connecting in relationships. (1st ed.). Portland, OR: Petersen Publications.
Hays, D. G. & Erford, B. T. (2014). Developing multicultural counseling competence: A systems approach. (2nd ed.). Boston, MA: Pearson Education, Inc.