Q&A: ‘Large, structural issues’ working against preventive care in rheumatology
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Editor’s Note: This interview between Healio and Drs. Philip Robinson and David Liew occurred in September. The editorial staff at Healio had been preparing to publish the resulting Q&A feature during the week of Jan. 2, when they learned of Robinson’s tragic death. We at Healio extend our deepest condolences to his family, friends and colleagues. The original Q&A feature in which Robinson appears is published below.
Among the many lessons of the COVID-19 pandemic, not just for rheumatologists but all health care professionals, has been the importance of preventive care for patients.
However, a variety of issues, including time restraints, an ongoing shortage of providers and the difficulty of applying new technologies at scale, have stymied the larger adoption of preventive care across rheumatology, according to experts.
Healio sat down with Philip Robinson, MBChB, PhD, FRACP, of the University of Queensland, in Brisbane, and David Liew, MBBS, PhD, FRACP, of Austin Health, in Melbourne, Australia, to discuss the critical issues inhibiting the wider adoption of preventive care strategies by rheumatologists.
Healio: What is the biggest challenge facing preventive medicine in rheumatology?
Liew: During COVID, we had all sorts of new innovations that came on quickly and we really needed to try and get it out there to implement it as quickly as we could. We struggled with that a lot, and I think that really highlighted some of the systematic issues that we have in implementing preventive medicine.
I don't think the biggest challenge in preventive medicine is necessarily infection prevention, or cancer detection, or cardiovascular risk calculation, or anything like that. I honestly think it's about how we can implement preventive medicine on scale quickly once we have, once we know the kind of people who we'd like to target.
Robinson: You can't apply preventive medicine if you don't know what you need to do or are not aware of the best strategies, and you also can't apply preventive medicine if you don't have time to do that, or potentially the skills. I think there are definitely large, structural issues that work against us, and then at an individual level it's about time and knowledge to a large degree.
Healio: What lessons did COVID-19 give to rheumatologists, and providers as a whole, regarding the importance of preventive care and getting that message out?
Liew: COVID showed us how good we are at this, and how bad we are at this. I think that in many ways we exceeded how well we thought we could do things, because of the urgency of the situation, and that we had this societal momentum, which rarely ever enters preventive medicine. People were thinking about vaccines and thinking about preventive therapies in a way that you would never ordinarily see.
But then I think it also highlighted to us, when we had to do this all of a sudden, our imperfect systems and our imperfect approaches to this, knowing that society was kind of waiting on us to protect our patients, because a lot of what was in place in broader society was there to try and protect immunosuppressed patients.
Robinson: Rheumatologists have a role in preventive medicine outside of the pandemic, including cardiovascular disease, osteoporosis, all these things. Part of the issue is that it's not entirely clear who owns preventive medicine. Most of the time primary care does these things, but primary care is busy. Primary care is busy doing lots of other urgent, right-in-front-of-us stuff, and so often these issues, this part does come down to knowledge as well. General practitioners don't necessarily know about the increased cardiovascular risk that comes with rheumatoid arthritis and that sort of stuff.
Healio: Is there anything that can be done to enable clinicians to better address these issues with their patients on a systematic or individual level?
Liew: There's a tendency to blame individual clinicians and say that we should just do more, but that's not practical. Even in an ideal clinic setting it’s just simply not practical, especially when we've got a workforce shortage that we do. When we don't have enough rheumatologists to see patients to do the core things within rheumatology, it's understandable that we don't necessarily want to suddenly schedule more visits or allocate more time for prevention. This is really about improving systems, because we really need to make this a system that works to be able to promote preventative medicine.
Robinson: This is all about knowledge and history. For example, people are very aware of diabetes now. There's lots of — at least in this country — special extra funding for diabetes because of the huge impact. Now it does have an outsized impact because of the prevalence of diabetes, but there's nothing for rheumatoid and cardiovascular disease — like literally nothing at all — except in academic journals and a few guidelines. No one outside of that really, and rheumatologists.
Healio: Are there any patient populations that require more concentrated efforts?
Liew: I think it's got a bit to do with disease and a little bit to do with demographics, and we need to consider the interaction between the two and every single patient that we see. I think we all know that there are patients for whom we need to take an extra step, but whoever they are, I think we need to try and understand better where they're coming from, what cultural contexts they are coming from, and what drives and motivates them. I think a big part of preventive medicine is motivational interviewing.
Robinson: As you get older you have cardiovascular risk. When you immunosuppress someone, they get more skin cancers. You know, if you give them steroids, you put them at risk for osteoporosis. And then add in the extra layers of what David was talking about, about sociodemographics and financial situations. There’s a very rare patient that you can sort of sit back and go, ‘Well no, you're sorted.’
There are always things that you can talk about — even outside of COVID times you could have talked yourself to death about vaccinations. You know, shingles, flu, making sure that people are up to date with all of these sorts of things. There is just so much that you could be doing, and part of it is about the trade-off and how much of a difference does getting a flu vaccination make.
Healio: What features do you want these systems to have?
Robinson: It's intelligence, not systems, that are flexible, that can use all the resources. You can think about all the different things that make this process easier. It's not just about us reaching out to them. It's about them engaging and coming back to doing the thing that we need to do. In COVID, you've got to tell them about where to get a vaccine, and where to go if they get sick, and where to get a test, and where to get antivirals.
Different people are engaged in different ways. Some people like pictures, and other people like words, and other people want a bit of paper, and other people want something on a computer screen.
Liew: This is one area where we can demand more collectively of the systems that we’re given. Electronic medical record providers probably don't hear us speak as one, that this is something that we want, but I think deep down we would all love the capacity to do that. They have the capacity to do a lot of this, and we need to demand more from them. I think we're all frustrated with the systems that we've been given, and those systems providers need to step up.
Healio: Do you have any way that you would like to see all kinds of providers come together to ask for more flexible systems?
Liew: We do need to have better ways to speak as a collective voice on this, and I think that we can’t just wait for that to happen. I think if we do have specialists, if we do find ways to have specialized solutions or clear advice, then it will be a lot easier to point to electronic medical record providers and say, ‘You're the bottleneck in this problem.’ It is about building that momentum, and I hope what we’ve been able to do with this viewpoint is to start a broader discussion in our community, and hopefully then it spreads to other communities as well.
Healio: What can the typical clinician do to offer more preventive care?
Robinson: There's two broad things. They need to think about how their systems can be made better, and start chipping away at it, which is asking for better systems. The other thing is that it is part of our day job to recognize when it’s critical that we do take those steps. When we see that rituximab (Rituxan, Genentech) patient who is unvaccinated in front of us, it really behooves us to actually say, ‘This is absolutely worth my time to sit here and spend most of this consultation talking about why it's really important that they have this.’ That's actually a life-or-death thing, because that patient has an 8% death rate.
You speak to 12 people that way and you’re going to save one life. While we’re talking about broader systems, and making the system better, we also need to recognize when it absolutely is worth our time to sit there and say, no, this is more important than what else we were going to address.
Healio: Is there any way to work on this across specialties?
Robinson: These medical record systems are not just used by rheumatologists. Advantages would go to all when these things are applicable and easy to use, and there are advantages and examples in every specialty where preventative care has value. It’s just not being done because it's not feasible to do it for a variety of different reasons, including time and the ability to do it. It’s all there waiting to be taken advantage of.
Healio: How do you get patients to engage and really take preventative care seriously?
Robinson: It's about engaging them and making them realize that it really matters to them personally, and to their family, if they wear a mask or they get vaccinated. It's the skills to impart the communication well, the motivational interviewing, the knowledge that this is an important aspect, and the time to deliver that. If you haven't got those things, then you’re not going to be able to get the risks and benefits, and that information, across to patients, so they’re not going to appreciate it. But if you take the time and you talk to them, then most patients say, ‘Well, OK, that sounds like a really good idea.’
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