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The Exchange Advanced Practice Clinicians in Rheumatology, Part 2

Advanced Practice Clinicians in Rheumatology, Part 2

Advanced Practice Clinicians in Rheumatology, Part 2 Posted By:
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As I alluded to in my previous post, there are often referrals to rheumatology from primary care clinicians that could be better handled. I have had many patients wait several weeks to see us in the rheumatology clinic for very simple, straightforward complaints. A very common one is fatigue. I have seen numerous patients referred to rheumatology for fatigue without any other complaints concerning for autoimmune or inflammatory disease—several times without any baseline laboratory studies completed. Countless times we have discovered nutritional and vitamin deficiencies, such as vitamin D, vitamin B12, and iron; thyroid disorders; or simply inadequate sleep due to lifestyle habits. It is unfortunate that a patient would need to wait several weeks to have an elementary work-up completed by a specialist that could have been appropriately managed by their primary care provider.

Another common issue we see in rheumatology is referral due to abnormal labs: A primary care provider may order a complete autoimmune panel even when the clinical suspicion of systemic autoimmune disease is very low or nonexistent, and if results are abnormal they tell the patient they have an autoimmune disease and need to see a specialist. Generally, a positive anti-nuclear antibody (ANA) is the most common referral we will see based on labs—however, rarely is autoimmune disease diagnosed solely from a positive ANA. The lab findings are pertinent to the clinical signs and symptoms of the presenting patient.

Almost always these patients will say, "I was told by my primary care provider that I have lupus." These patients come to us very anxious and concerned, and are difficult to get adequate information and accurate histories from. Frequently, we have to console patients who have been experiencing significant distress for weeks due to misdiagnosis by primary care.

As a rheumatology advanced practice clinician, I recommend that, rather than causing unnecessary distress, primary care clinicians tell their patients that some of their labs are abnormal, and based on that patient's specific symptoms they recommend an evaluation with a rheumatologist to further assess the concern and determine if treatment is necessary.

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