This story is told with permission from Mr. Stone. Written, informed consent and release of information forms are on file.

I recently saw a kindly, intelligent, organized gentleman as a follow up for RF and CCP positive rheumatoid arthritis with a marked response to 15mg weekly of methotrexate. He also has osteoarthrosis with clear osteophytic changes in his hands and knees on exam. It was unclear to me if his current pain was because of residual inflammatory disease versus mechanical degeneration.

All in all, a fairly typical case and encounter that I wouldn’t have thought about more–except to remember our conversation about old soda machines–until I happened to glance at my original consult note.

Backstory

Mr. Stone had seen me as a third opinion for joint pain. His first rheumatologist, an experience clinician whom I have great respect for with regards to his scientific acumen and testing thoroughness, was suspicious for rheumatoid arthritis in addition to his osteoarthrosis in the setting of high positive RF and CCP, except that he never found any synovitis on exam1. He treated him conservatively with steroids and hydroxychloroquine (Plaquenil) and followed him closely.

Again: typical presentation, typical problems, and a typical approach to a yet undefined disease.

Then, the patient’s insurance insisted on a “second opinion” by a company called “Best Doctors”.

This so-called second opinion was obtained by sending the patients records to a rheumatologist at Harvard. I know this because in his typically organized fashion, Mr. Stone brought the records with him to that first visit. These included the report from Best Doctor’s which was basically a rehash of a rheumatologist’s letter written on Harvard business stationary.

The salient quotes were:

“Dr. [redacted] thinks that you should see another rheumatologist for a second opinion. Dr. [redacted] does not think that your symptoms or presentation are consistent with rheumatoid arthritis.”

“In as much as the diagnosis of ‘rheumatoid arthritis’ has been raised, assays for rheumatoid factor and anti-CCP should be obtained, in the interests of completeness.”

Moral outrage

In reading this report and seeing how it had damaged the reputation of the first rheumatologist in the eyes of this patient, I could not fail to feel moral outrage at the unjustified arrogance before me.

First, the assays had already been tested and were highly positive, which was why there was the concern for rheumatoid arthritis in the first place. This was clearly stated in the first rheumatologist’s clinic notes. It was also why lacking synovitis on exam, I wanted to follow up with him rather than writing him off after the first visit with osteoarthrosis.

Second, how could any right-thinking rheumatologist think he could make a clinical diagnosis without taking a history and performing an exam? More than most specialities, rheumatology relies on history and exam. If you are going to question the judgment of another rheumatologist, certainly you also have to question their history and exam. Also, any doctor knows that we see and hear far more than we ever document. Thinking you know the story from reading the notes is a potentially fatal mistake.

At the time I discussed this so-called second opinion with my colleagues decrying the fact that any doctor would be so arrogant to think they could diagnose a clinical disease without taking a history or exam. It seemed even worse in a field where most of our diseases are diagnosed clinically with our tests being lamentably poor.

We live in a world of fancy tests in which the FBI can recover DNA off of licked envelopes from decades past and civilians can skydive from space. In many areas we can do the impossible, and many except the same magic everywhere. They expect that an MRI or lab or biopsy actually shows the cause of their symptoms, when we all know that these are poor tests at best with limited sensitivity and specificity. We need to be the ones holding the line, reminding everyone else that this is still, for now, a clinical field. It is messy, dirty, and ugly–like me before my morning coffee.

Present day

At my initial consult with Mr. Stone, I did not see any synovitis. My opinion was basically the same as his first rheumatologist. The caveat was that he was on steroids, which can mask the exam findings of rheumatoid arthritis. So we agreed to stop these and follow up in three months. 21 days later he was back in my clinic with obvious synovitis and a warm effusion of the left knee. Based on the new ACR classification criteria, and more importantly my clinical judgment, he had RA. We agreed to start him on methotrexate 15mg weekly.

Today he told me that he is much better. His synovitis has resolved. Most importantly in my opinion, he tells me that he’s out working on roofs, which he wouldn’t have been able to do 6 months ago. He still has some pain and we will be working to determine if this is only due to old mechanical pains or if there is still some inflammatory component in need of suppression.

Wrap up

Really, his case isn’t that remarkable to a rheumatologist. If it wasn’t for the “Best Doctors” involvement, I would never even mention a case like this to another rheumatologist. What makes it so remarkable is when the opinion of a doctor who has talked to or examined a patient takes precedence over the clinician who was in the room for that is what we do. We listen to a story. We examine. We might order some labs or other testing. Then we guess, place our bets, and see what happens.

What “Best Doctors” got wrong is to skip the story and the exam. Maybe one day we will have better labs, better scans, better pathology and we won’t need to do that stuff anymore. Maybe one day doctors will be more technicians than magicians. More likely, we won’t be needed anymore as a computer will be able to perform the task better. But we are here and now. And if your rheumatologists doesn’t touch you, they’re wrong.

I don’t write this to shame anyone, but to serve as a reminder to myself first, and to other rheumatologists second, that the science of medicine is poor, the art primary, and the history and exam paramount.

Update 2.18.2013: Prior to ever seeing me, Mr. Stone had been referred to the Mayo clinic for evaluation. With my knowledge and approval, he kept this visit that occurred after the initial publishing of this post. They agreed with the diagnosis of rheumatoid arthritis and suggested that if labs showed any evidence of active inflammation to consider adding a biological. The labs were negative. So, all doctors who actually saw the patient have diagnosed him with RA or thought that was a good possibility. All doctors who didn’t see the patient missed the diagnosis. As we move into the future with telemedicine, we must be very careful.

  1. He was on steroids, which could have been masking the findings.