Rheumatology meds

[Toohotinvegas33]

Besides steriods/Nsaids/SNRI's, which other meds are appropriate for a FM doc in an urban setting to prescribe? Specifically, with the appropriate experience would it be wrong to write/manage someone on methotrexate or sulfasalazine?

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[cabinbuilder]

No, I do it all the time. Even though I am in a rural area. The RA patients see their rheumatologists once a year, get meds adjusted. We monitor their labs how t he specialist requests and refills the med accordingly. I do enbrel injections too.

 

[Toohotinvegas33]

But would you make a dx and start the meds without rheum seeing the patient?

 

[cabinbuilder]

But would you make a dx and start the meds without rheum seeing the patient?

I would if I get the labs done and many times I can fax labs to a rheum who I can consult with who would help with initiating treatement. My nearest rheumatologist is 4 hours by plane. Just depends on comfort level. I don't always have the luxury of referring since patients don't have the money for travel since everything from Southest Alaska is by air or ferry.

 

[deleted87716]

The OP asked about an "urban setting," which I assume means that consultants are available. In that instance, regardless of your comfort level, I think you'd be taking a chance. In the event of a bad outcome, you'd have witnesses for the plaintiff lining up to say, "I'd have referred them to rheumatology." Don't be a cowboy.

 

[smq123]

The OP asked about an "urban setting," which I assume means that consultants are available. In that instance, regardless of your comfort level, I think you'd be taking a chance. In the event of a bad outcome, you'd have witnesses for the plaintiff lining up to say, "I'd have referred them to rheumatology." Don't be a cowboy.

Not necessarily. I work in an urban setting, and many of our patients have the local county insurance, which only approves referrals for acute conditions. This excludes hepatitis C, any autoimmune diseases, and HIV. I had a discussion last week with one of the other docs about this, and she half jokingly said that we were essentially practicing wilderness medicine in the middle of the ghetto.

 

[deleted87716]

I work in an urban setting, and many of our patients have the local county insurance, which only approves referrals for acute conditions. This excludes hepatitis C, any autoimmune diseases, and HIV. I had a discussion last week with one of the other docs about this, and she half jokingly said that we were essentially practicing wilderness medicine in the middle of the ghetto.

That's f'ed up.

From a medicolegal perspective, "But, your honor, the patient had bad insurance" offers you no protection, unfortunately.

 

[smq123]

That's f'ed up.

From a medicolegal perspective, "But, your honor, the patient had bad insurance" offers you no protection, unfortunately.

True. Working in a FQHC takes a little of the pressure off....not much, but some.

 

[lowbudget]

I've diagnosed some RA and put them on methotrexate. I "got my experience" working with uninsured patients, because no one else wanted to see the patient and I documented in the chart that the patient has no insurance, that reasonable attempt at getting them specialty care was attempted, but the patient does not have access at all. You still need to follow the standard of care for the treatment of the disease and everything associated with the treatment. If you don't know what the standard of care is, ask.

If your patients are uninsured and you're not comfortable, ask the patient to pay cash to see the rheumatologist one time and get their opinion. Make it a good visit by having all your notes and labs and imaging available for review (give them a complete "package"). Most reasonable patients will understand and will save up money to make that appointment even if it takes months to save up enough cash to afford the office visit. When you explain well and communicate well, patients will trust you and they will follow through. But it's your job to develop that trust and sell it.

It's interesting. When my patients have insurance, I'm sooo not qualified to take care of my patient according to some people; but when my patients have no insurance, all of a sudden I'm more than capable.

I once told my pulmonary attending as a 2nd year resident that I wasn't comfortable starting a patient on amikacin because I had no experience doing so. He scoffed and as he walked away from me, peered over his shoulder and said, "well get some experience then."

One amikacin, coming up. But you better d8mn well believe that I did everything I could to learn about amikacin.

 

[deleted87716]

I've diagnosed some RA and put them on methotrexate. I "got my experience" working with uninsured patients, because no one else wanted to see the patient and I documented in the chart that the patient has no insurance, that reasonable attempt at getting them specialty care was attempted, but the patient does not have access at all. You still need to follow the standard of care for the treatment of the disease and everything associated with the treatment. If you don't know what the standard of care is, ask.

Correct approach.

FWIW, the poor and uninsured are less likely to sue you, too.

 

[cabinbuilder]

Not necessarily. I work in an urban setting, and many of our patients have the local county insurance, which only approves referrals for acute conditions. This excludes hepatitis C, any autoimmune diseases, and HIV. I had a discussion last week with one of the other docs about this, and she half jokingly said that we were essentially practicing wilderness medicine in the middle of the ghetto.

I totally believe that. Had similar experience with the Community Health Center in Pueblo, CO. Either the patient is medicaid, private pay on sliding scale, migrant worker program, or the homeless program. Cant' refer anyone because no specialists would see any of these people. I was lucky to have OB and Ortho in the building for the severe cases. Most everything that came through the door I just had to deal with it.

 

[Toohotinvegas33]

Great posts, thanks for the insight. I also find it interesting that if they have no money or insurance society is ok with us managing a condition that would normally be referred.

I don't plan on being a cowboy, but when I'm told that a medication that they prescibe daily is very safe with appropriate monitoring, I dont understand why it should be an automatic referral. I even found this little gem from the ACP

http://www.aafp.org/afp/2000/1001/p1607.html