Consultant physicians working with patients - Royal College of ...

Consultant physicians working with patients4 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingRheumatologists have long advocated MDT working. 13This is embedded in the British Society forRheumatology (BSR)’s guidelines on the managementof rheumatoid arthritis, 14 the Arthritis andMusculoskeletal Alliance (ARMA)’s standards of care 15and NICE clinical guideline CG79. 16Consultant rheumatologists are supported byrheumatology nurse practitioners, physiotherapists,occupational therapists, podiatrists, psychologists andorthotists. Nurse practitioners play a key role indelivering direct-access helplines, drug monitoring,rapid-access clinics, nurse prescribing, patienteducation and counselling. 17 Support regardingactivities of daily living and occupation for disabledpatients is important, including provision ofinformation on benefits agencies and liaison whereappropriate with community care agencies. Pharmacistshave a role to ensure patient safety, to help with drugmonitoring and to promote the introduction of newertreatments, eg biologic agents, through drug andtherapeutics committees. Pharmacy databases can alsoprovide units with data to assist audit.Working with other specialtiesCombined clinics provide an opportunity to coordinatecare for complex patients (eg with dermatology,respiratory and renal medicine), run dedicated clinicsfor paediatric and adolescent (transitional) patients andenable access to orthopaedic surgery. Specialist adviceshould be available throughout antenatal and postnatalcare for individuals with diseases such as lupus andantiphospholipid syndrome. It is also important toestablish good links with general orthopaedic, painmanagement and musculoskeletal radiology services,including dual-emission X-ray absorptiometry (DXA),magnetic resonance imaging (MRI) andmusculoskeletal ultrasound services.Working with GPs and GPs with a specialinterest (GPwSIs)The relationship of rheumatology units with primarycare is evolving rapidly, driven by the MSF 10 and thedevelopment of GP consortia in England. Trainingschemes for GPs often include rheumatology, and GPsmay join the MDT as clinical assistants. However,expansion of GPwSIs has led to the possibility ofstand-alone community clinics, sometimes locatedwithin the CATS. Unfortunately, collaboration betweenGPwSIs and rheumatology units has not always beenestablished, which causes concern about poorcoordination of care, quality, training and governance.The BSR has a curriculum with a competencyframework for GPwSIs. 18 Clinical governanceprocedures must be robust, and the BSR hasrecommended that GPwSIs work in close liaison withrheumatology units and take part in CPD. Similarprinciples apply to the development of new integratedrheumatology services.5 Delivering a high-quality serviceWhat is a high-quality service?High-quality rheumatology services should bepatient-centred, accessible and multidisciplinary(Tables 3–5): Enhancing quality of life (including preserving theability to remain in work) and ensuring people havea positive experience of their care are central aspectsof a high-quality service. Access to the service must be equitable, prompt andphysically suited to those with disability. Care must be collaborative to allow integration andcontinuity across primary, intermediate, secondaryand (for some conditions) tertiary services. A strongMDT is pivotal for this.6 Clinical work of consultantsThe BSR recommends that no single-handed consultantrheumatologist should work in isolation or be expectedto provide an acute general medical service.Outpatient workRheumatology is an outpatient-based specialty.However, wide variation exists in the total number ofclinics per consultant, which depends on the geographyof the service, involvement in acute medicine, provisionof community clinics, academic interests and otherduties including teaching and management.The expected workload is based on recommendations ofbest practice from the BSR. A full-time consultantrheumatologist would be expected to undertake 4–5clinics a week and those who perform general internalmedicine (GIM) 3–4 clinics a week. These wouldinclude routine clinics, special clinics (eg lupus clinicsand fracture prevention clinics) and combined clinics(eg with orthopaedic surgeons). Some consultants nowundertake musculoskeletal ultrasound and report onbone-density scans.238 C○ Royal College of Physicians 2013