Rheumatology fellowship: Help needed; future outlook

[NewYorkDoctors]

Side Question . This is related to the field of rheumatology but I did not feel this merited another thread being created

For DM and cancer screening or chronic corticosteroid use and assessing for screening for long term side effects of CS use, how active a role do you normally take as the rheumatologist?

I get in academics the PCP would be the "quarterback" in a linked EMR, but in PP things are loose and disconnected.

For the patients with DM / ILD, I often get all the cancer screening like the internist myself because I have found when I made recommendations to PCP in the community ,things do not always get done.

Same thing goes for whenever I put someone on chronic CS for asthma or EGPA (hopefully nucala knocks down the CS but still), if they are in the proper risk group I'll manage the DM, the referral to optho, the evaluation for AVN of hip, the osteopenia and osteoporosis , etc... as well using my Internist level knowledge.

Just curious what your practices are regarding this.

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[mszzeta]

Side Question . This is related to the field of rheumatology but I did not feel this merited another thread being created

For DM and cancer screening or chronic corticosteroid use and assessing for screening for long term side effects of CS use, how active a role do you normally take as the rheumatologist?

I get in academics the PCP would be the "quarterback" in a linked EMR, but in PP things are loose and disconnected.

For the patients with DM / ILD, I often get all the cancer screening like the internist myself because I have found when I made recommendations to PCP in the community ,things do not always get done.

Same thing goes for whenever I put someone on chronic CS for asthma or EGPA (hopefully nucala knocks down the CS but still), if they are in the proper risk group I'll manage the DM, the referral to optho, the evaluation for AVN of hip, the osteopenia and osteoporosis , etc... as well using my Internist level knowledge.

Just curious what your practices are regarding this.

I will screen and manage osteoporosis/osteopenia in those who are on steroid. For DM you mean type 2 diabetes? diabetes screening/management and age-appropriate cancer screening should be PCP's responsibility. I know not all PCPs are good (see how many low back pain and "incidental" pos ANA I got from community NPs). But unfortunately, it would not make any sense to do both rheum and PCP work at once, without a double pay. I am very comfortable managing CHF, but I don't do it on my patients...

 

[NewYorkDoctors]

I will screen and manage osteoporosis/osteopenia in those who are on steroid. For DM you mean type 2 diabetes? diabetes screening/management and age-appropriate cancer screening should be PCP's responsibility. I know not all PCPs are good (see how many low back pain and "incidental" pos ANA I got from community NPs). But unfortunately, it would not make any sense to do both rheum and PCP work at once, without a double pay. I am very comfortable managing CHF, but I don't do it on my patients...

Oh I meant dermatomyositis . I should have not used that confusing short hand . I was referencing how dermatomyositis patients have a higher risk of malignancy. I have a few patients with organizing pneumonia secondary to dermatomyositis and I had recommended by paper and phone call to pcp about need for vigilance for cancer screening … crickets … so I have been doing all that myself since the patient sees me more often and I feel I may as well get that done for the patients sake and no one sues me …

 

[mszzeta]

There is no hard rules re cancer screening in dermatomyositis, due to severe lack of evidence. There are a couple of expert consensus, but I would say their evidence is very low to form a standard care. (we know that there is a higher risk of cancer. The question is, will screening save lives, versus the risk of false pos, "overdiagnosis", anxiety...... We don't know how many lead-time bias, length-time bias are there) I only perform additional screenings for TIF-1 gamma pos dermatomyositis. And there is a recent paper from the Hopkins cohort suggesting an overall low yield of cancer screening for dermatomyositis population (https://acrjournals.onlinelibrary.wiley.com/doi/full/10.1002/acr.25114)

For the age-appropriate cancer screening, I sometime ask my patients explicitly to ask their PCP about pap smear, mammogram and colonoscope...