Historically, people who hurt would see their primary care practitioners. When diagnosed with rheumatology disorders, these patients are often swept into the maze of medicine, therapies, surgeries and follow-ups. Extensive resources and public awareness have indeed put a face on rheumatology. While emerging research has resulted in a considerable expansion of promising treatment options, patients are also obtaining health care information from a variety of sources.

In my experience, patients receive their information from three main sources: the media, medical professionals and “mentors.” All of the information from these sources may become intertwined and can have a positive or adverse impact on the management of these patients.

When asked, my patients say they rely on health care professionals, whether it is a family medicine clinician or a specialist, as their primary source of medical information. I believe primary care physician assistants (PAs) are in an ideal position to address concerns that are perhaps not well reviewed by the patient's rheumatologist or other specialists.

Pertinent topics comprise three lifestyle issues. One should encourage a proper diet to maintain a healthy weight and emphasize healthy, nutritious foods. Folic acid is associated with heart health, prenatal prevention of neural tube defects and is also indicated for use with methotrexate. It is incredibly easy for us to advise patients to consume whole grain bread and rice and, like we say in the south, “eat your greens.” These foods provide folate, fiber and other benefits such as calcium.1

Activity is necessary to maintain muscle strength, and support and maintain deteriorating skeletal components due to the disease process. Clinicians must also address tobacco use with all patients including children as it has been associated with a less favorable prognosis in patients with rheumatoid syndromes.2

Physician assistants should encourage patients to pursue gentle exercises such as swimming, water aerobics or t'ai chi, which are minimally weightbearing activities that help promote strength and balance. In addition, these disciplines provide positive mental benefits and impart socialization that many patients have difficulty pursuing as their disease progresses.3

The issue of heart and lipid health is tantamount as patients with rheumatoid disease have an increased cardiovascular risk on par with diabetic patients. For these patients, one must consider cardiac and lipid-lowering medications but do so with extreme caution with respect to other treatment regimens.1 For example, one should be very cautious when it comes to weighing some of the new anti-TNF medications — if you use them at all — to treat patients with rheumatoid disease who have comorbidities such as congestive heart failure (CHF), tuberculosis, lupus and other considerations such as recurring infections.4

Helping Patients Assess Their Pain

-By Charlene M. Morris, MPAS, PA-C Certainly, when treating patients suffering from pain, it is worthwhile to have a tool that quantitatively measures treatment effectiveness. This tool can give patients and treating clinicians a means of reviewing even minimal improvements over time. However, keep in mind your patient's ability to read when determining which measurement method you utilize in your practice. Simply ask a patient, “Can you read well?” Producing a visual analog scale (VAS) can surmount a patient's embarrassment. The VAS can show a happy face to represent “no pain” at the low end of the scale and gradually progress to a tearful, unhappy face to represent overwhelming pain at the high end of the scale. For a more high-level patient, clinicians may employ the disease activity score, including a 28-joint count (DAS28), to assess patient response and appreciate this over the continuum of treatment.10

Separating Medical Facts From Media Hype
Although it is good there is more awareness of rheumatoid disease, the media has recently captured the public eye with glowing television ads for Enbrel (etanercept). Antiinflammatory medications, including the now controversial COX-2s, have also shared the television screen and glossy pages of popular magazines that are often in office waiting rooms.

A recent search of the Internet web site Google (www.google.com) for “rheumatoid diseases” produced no less than 155,000 replies. Even if we do not utilize the Internet for our practices, many of our patients surf the web for their disease management and may unfortunately embrace what they read. There is a difference between medical fact and information although it is constantly changing even within our own literature and the medical community.

Taking a moment to ask and listen gives us the opportunity to understand how the person perceives his or her disease, and gauge the patient’s interest in his or her treatment. Taking this time also establishes the foundation of a solid patient/provider relationship.

Understanding The Influence Of Various 'Mentors' and Alternative Therapies
While I personally welcome informed and interested patients, participation in their illness is different from embracing therapies and medications that may not be appropriate for them. Unfortunately, this happens without our knowledge.

While some of the items Amish practitioners give are benign, a cardiologist colleague was recently devastated when her patient was advised by an Amish practitioner to discontinue her coumadin and subsequently died. As clinicians, we must emphasize to our patients that they discuss any change of treatment regimen with us before they add therapies or cease taking treatment. It is a fundamental step that can save patient lives.5
At every patient visit, ask the patient what medications he or she is taking. Specifically ask about over the counter (OTC) medications, herbs, dietary supplements, balms and recreational drugs. For example, BC and Goody powders are popular OTC aspirin products that are used in our rural community. Uncommon examples include items ranging from bee pollen to deer antler, which have been used to treat rheumatoid disease.
Researching what patients may be using and being aware of concomitant drug/drug interactions is imperative to quality care. Unless you ask about these reatments, the patient may not tell you.

“What else are you doing for your disease?” is the second query I ask patients. Chiropractors are licensed practitioners in all states and the military, and they invariably receive high satisfaction marks from their patients. Therapies include “adjustments,” heat, massage and touch. While chiropractors are not accepted by many allopathic practitioners, they flourish because of their attentiveness to patient concerns.

Many allopathic, Western clinicians as well as Chinese practitioners are using acupuncture. Repeated studies show that acupuncture can be an effective adjunct treatment for pain and rheumatoid disorders although there is currently no extensive, definitive research on this subject. One interesting note is that children seem to respond well to acupuncture over 50 percent of the time.6,7

Friends, family and community members often have advice for our patients. It is common and definitely human nature to look for the magic medicine that will provide relief and wellness. These same non-medical sources that refer to us may provide barriers to our best efforts. Many patients are frightened to take narcotics, even postoperatively because of the potential for addiction. There is definite public wariness and fear surrounding the recent approval of thalidomide for rheumatoid disease as the drug was vilified and removed from the market in the 1960s.8

Final Notes
Physician assistants are in the ideal position to be advocates for our patients and a true liaison between the specialty practices and primary care medicine. With our guidance and vigilance to treatments and patient concerns, we can offer the most comprehensive, effective care for patients with rheumatoid disease.9