Rheumatology Advance Access originally published online on November 18, 2006
Rheumatology 2007 46(3):377-378; doi:10.1093/rheumatology/kel362
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EDITORIALS |
What is a rheumatologist for?
The British Society for Rheumatology, Bride House, 18–20 Bride Lane, London EC4Y 8EE, UK.
Correspondence to: Debbie Smith. E-mail: dsmith{at}rheumatology.org.uk
Ask any individual rheumatologist, and I suspect that the answer will be clear. Collectively, however, our specialty includes the management of a diverse range of conditions ranging from life-threatening vasculitis, inflammatory arthritis and osteoporosis to soft tissue pain and chronic pain. In the UK, current dogma from the health commissioners dictates that much of this activity might be taken away from the specialty and given to other clinicians such as primary care doctors and nurse or physiotherapy practitioners on the grounds of cost saving. This change in emphasis is potentially a major threat to rheumatology as a specialty and the rheumatologist as an individual. This reflects the suggestion in a recent White Paper ‘Our health, our care, our say’ [1] that care be devolved from secondary to primary care.
In England, the Department of Health has just published (August 2006) its own ‘Musculoskeletal Strategy’ [2], a document that sets out to define best practice in providing care for ‘people with musculoskeletal conditions’. There is much to welcome in this publication and, indeed, it has been endorsed by the British Society for Rheumatology (BSR) along with other arthritis-related charities. Within, a major recommendation is for the establishment of a clinical interface between primary and secondary care, on the basis that such a service modification will improve efficiency, provide treatment closer to the patients’ home and, with triage, reduce inappropriate referrals to both orthopaedic and rheumatology departments in secondary care. Such a service has been given a new acronym of CATS (Clinical Assessment and Treatment Service). The contribution of the rheumatologist to the workings of such a service is suitably vague but the implication is that much clinical activity will be taken away from what is now our traditional workplace in secondary care—the hospital. The taking-away will either mean that Consultant Rheumatologists will abandon some types of clinical work, or that they will do it in a primary care setting, or both.
The BSR has in the past defined rheumatologists as: ‘doctors who have had extra training in order to become experts in diagnosing and treating arthritis and other rheumatic diseases. Most are based in hospital rheumatology units, although a few also work at clinics at local health centres. The rheumatologist will work closely with you, your GP, and other specialists, to find out what is wrong with you and how best to treat it.’ [3].
In the ‘Musculoskeletal Strategy’ is a contemporary definition: ‘Rheumatologists specialise in managing the inflammatory disorders affecting the musculoskeletal system, including rheumatoid arthritis and ankylosing spondylosis. They also have a general interest in musculoskeletal pain and some may have a special interest in other conditions, such as osteoporosis.’ [2].
Also in this document, there is a much longer definition of a ‘GPwSI’ (general practitioner with a special interest), which includes: ‘GPs have developed special interests within the orthopaedic/musculoskeletal fields, including rheumatology, specific joint referral assessment clinics, back pain assessment and management services, menopausal and osteoporosis services, and sports medicine.’ [2].
It might be argued, therefore, that the modern view of a rheumatologist as seen by those outside our specialty is a doctor who specializes exclusively with inflammatory conditions, leaving the rest to others such as GPwSIs along the lines of the definition given above. The BSR's own definition is more encompassing.
Does this matter? Many English rheumatologists already have (and have indeed had for many years [4]) a variable casemix when compared with each other and dependant on factors such as workplace, academic and special interests and, therefore, a possible argument might be that any restructuring will make little difference. In contrast, here at the BSR, we believe that defining a modern rheumatologist really does matter and it is crucial that, as a specialty, we can agree on a definition. There is a danger that despite all the recent success in raising our profile, the specialty will be subsumed into primary care or sink back to become again a minor specialty in the hospital setting. And there is the issue of general medicine: for decades rheumatologists have been trained to fill a variety of differing posts, depending on whether they have an interest in rehabilitation, general or academic medicine. It might be seen as helpful by general physician colleagues trying to reduce their own on-call commitments, if more rheumatologists were available to do acute medical takes—and such availability would be achieved by promoting a withdrawal of rheumatologists into secondary care-based inflammatory disease only.
What are the options, therefore? First, we could concentrate our practice purely on inflammatory diseases, which is a model of rheumatology care practiced successfully in other European countries. This could lead to a contraction in our specialty and, of course, would have important implications for training. Second, we could place the rheumatologist at the heart of this new interface (CATS) and position our specialty at the head of musculoskeletal medicine as a whole. This second option would have the advantage of ensuring that the rheumatologist is proactive in the design of local service delivery, but may be a commitment too far for those who already have a very heavy clinical workload. These options are possibly too stark and the position might be in some form of compromise between the two, but a meaningful definition here could be tricky.
Whatever the deliberation of our specialty, the best interests of our patients must remain central to any repositioning. It is important that we examine closely the clinical and cost implications of making changes. Is it reasonable to argue that general practitioners are generally able to do ‘basic’ rheumatology, or is their training in fact inadequate for safety? Is it cost-effective to pay specially trained GPs either to work as GPwSIs or to run triage systems? Is it acceptable, as implied in the musculoskeletal strategy, for triage systems to use non-medical practitioners such as chiropractors? Is it cost-effective to run secondary care clinics in a primary care setting? And are there risks from all of these proposals—and, if so, do the risks outweigh the benefits?
This article does not come with any answers but a request for a robust debate. At the BSR, we would very much welcome your views. A session at the 2007 AGM will debate some of these issues.
The authors have declared no conflicts of interest.
References
- Department of Health (2006). (2006) Our health, our care, our say: a new direction for community services(Department of Health, London).
- Department of Health (2006). (2006) The Musculoskeletal Services Framework(Department of Health, London).
- British Society for Rheumatology. Information on file (BSR, London).
- Bamji A, Dieppe P, Shipley M, Haslock I. (1990) What do Rheumatologists do? A pilot audit study. Br J Rheumatol 24:295–8.
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