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The private practice of rheumatology. the first 1000 patients

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I304
THE PRIVATE PRACTICE OF RHEUMATOLOGY
The First 1,000 Patients
ANTHONY BOHAN
Although this report of the first 1,OOO patients in
a rheumatologic consultative private practice cannot
necessarily reflect the general experience of rheumatology, certain conclusions may be valid and may help to
guide the rheumatologist-in-training. Approximately
70% of our patients were categorized as having “inflammatory” or “connective tissue’’ disorders, rather than
degenerative disorders. Internists and general practitioners were the principal referral sources. Over 80% of
referrals came from a relatively small geographic radius
of 10-15 miles. A population base of perhaps 200,000
people, therefore, may be necessary to support a purely
rheumatologic practice. A relatively steady flow of 2
new patients per day was not significantly influenced by
subsequent additional rheumatologists moving into the
area. However, the pattern of referrals clearly changed
to include more patient-to-patient referrals (nearly
30%), perhaps reflecting both loss of physician referral
sources and the increasing number of referrals from
satisfied patients over a period of time.
The transition from a university medical center
training program to the private practice of consultative
rheumatology is associated with numerous uncertainties and anxieties. This is a particularly unsettling
situation because little data exist in the literature to
shed light on the characteristics of a private practice in
consultative rheumatology. Although several reviews
and analyses on the community practice of other
Address reprint requests to Anthony Bohan, MD, Clinical
Assistant Professor of Medicine. Department of Medicine, Division
of Rheumatology. UCI Medical Center, Orange, CA 92668.
Submitted for publication September 8, 1980: accepted in
revised form February 25, 1981.
Arthritis and Rheumatism, Vol. 24, No. 10 (October 1981)
specialties may be found (l-3), similar descriptions of
a rheumatologic practice are few (4S).
In an effort to help fill this void, this report is an
analysis of the first 1,000 patients seen in a consultative rheumatologic practice by a board-certified rheumatologist. The characteristics of the practice are
divided into the areas of I ) types of patients seen; 2 )
demographic data; 3) referral sources and patterns of
referral; 4) growth patterns; 5 ) effect of additional
rheurnatologists; 6) followup data and the population
base needed for a rheumatology practice.
METHODS
Newport Beach is a Southern California coastal city
of 15.7 square miles, with a population of 60,300.Located in
Orange County. it is approximately 50 miles south of Los
Angeles. In 1975, there were a total of 8 rheumatologists in
Orange County. I was the first rheurnatologist in Newport
Beach.
All patients were referred for rheumatologic consultation, and no internal medicine patients were seen. Every
patient was comprehensively evaluated by eliciting a complete medical history, physical examination, complete blood
count, urinalysis, sedimentation rate, serologic studies. routine chemistry profiles, and radiographs of appropriate
joints.
‘The first 1.OOO patients seen in the office over the
initial 2 years of the practice comprise the basis of this
report.
RESULTS
There were 27.4% male and 72.6% female patients. The average age was 49.4 years with a range
from 6 to 85.
Rheumatoid arthritis was the most frequently
seen disorder, occurring in 31.1% (Table I ) . Degenerative joint disease accounted for 21.2%. and bursitis
PRIVATE PRACTICE OF RHEUMATOLOGY
Table 1. Diagnosis in I ,ooOconsecutive patients
Diagnosis
Rheumatoid arthritis
Degenerative joint disease
Uncertain or undetermined
Myofascial pain syndrome
Bursitis/tendinitis
Ankylosing spondylitis
Psychogenic rheumatism
Systemic lupus erythematosus
Keiter’s syndrome
Low back syndrome
Psoriatic arthritis
Gout
Raynaud‘s disease
Costochondritis
Polymyalgia rheumatica
Sarcoidosis
Neuropathyheuritis
C hondromalacia
Scoliosis
Occult malignancy
Sjogren’s syndrome
Henoch-Schonlein purpura
Gonococcemia
Internal joint derangemenr
Arachnoiditis
Muscle s(rain
Sudek’s arthropathy
Crohn’s disease
Chronic active hepatitis
Stiff-man syndrome
Idiopathic myokymia
31.1
21.2
11.3
4.7
4.5
3.7
3.3
2. I
1.8
1.4
1.2
1.2
I .0
0.8
0.6
0.6
0.6
0.4
0.4
0.4
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.2
and tendinitis occurred in 4.5% of patients. Other
inflammatory arthritides included ankylosing spondylitis (3.7%), Reiter’s syndrome (1.8%), juvenile rheumatoid arthritis (1.6%), psoriatic arthritis (1.2%), and
gout ( I .2%).
The connective tissue disorders included
scleroderma (2.5%), systemic lupus erythematosus
(2. I%), and polymyositis and dermatomyositis (1.8%).
Psychogenic rheumatism was diagnosed in
3.3%. Approximately 11.3% of the patients could not
be clearly classified.
An analysis of referral sources indicated that
most of the referrals came from internists (26.5%) and
general practitioners (22.4%) (Table 2). Orthopedic
surgeons accounted for 9.596, and a similar number of
patients were self-referred. The local chapter of the
Arthritis Foundation referred 4.9%. “Overflow” patients from another rheumatologist accounted for l .2%
of the patients.
The majority of patients (27.8%) came directly
from Newport Beach (Table 3). The area within a 10-
I305
15 mile radius with a population base of 777,507
accounted for 80.7%. The contiguous communities of
Newport Beach, Costa Mesa, and Irvine, with a total
population of 165,000, produced 52.3% of all referrals.
The average number of patients referred monthly was 42.8, or 2.1 daily. The first 2 months of practice
proved to be the most active with referrals that clearly
represented a backlog of cases that had accumulated in
the community because of the lack of a locally available consultant rheumatologist.
The average length offollowup was 12.9 weeks.
Patients with inflammatory arthritides and connective
tissue disorders averaged a followup period of 18.2
weeks, while patients with degenerative disorders
returned on an average of only 7.4 weeks.
By 1980, additional rheumatologists moving
into Orange County increased the ranks of rheumatologists from 8 to a total of 20 in Orange County itself,
and now there are 2 in Newport Beach. The influx of
additional rheumatologists did not appear to change
the number of patients referred, which remained at
approximately 2 daily.
DISCUSSION
The characteristics of any single practice cannot necessarily be extrapolated to the general practice
of rheumatology. In fact, the Orange County area and
the city of Newport Beach themselves are somewhat
unusual compared to other areas, at least in the sense
that medical services in the area are “overspecialTable 2. Referral resources
Resource
Internists
General practitioners
Orthopedic surgeons
Self-referred
Arthritis Foundation
Friends
Ob-Gyn
Orange County Medical Center
Neurologists
Relatives
Hoag Memorial Hospital
Surgeons
Neurosurgeons
Overflow
Workman’s Compensation
Orange County Medical Association
Urologists
Psychiatrists
Dermatologists
Miscellaneous
9%
26.5
22.4
9.5
9.5
5.9
4.7
4.1
2.5
2.9
2.7
2.1
I .9
I .8
1.2
I .0
0.8
0.6
0.6
0.4
I.4
BOHAN
1306
Table 3. Referrals by geographic areas
Area
Newport Beach
Costa Mesa
Santa Ana
Huntington Beach
Irvine
Fountain Valley
Westminster
Laguna Hills
Garden Grove
Laguna Beach
Anaheim
Laguna Niguel
Tustin
Orange
Mission Viejo
South Laguna
Miscellaneous, up to
Out of county, up to
*-
=
Distance, miles
%
Population*
-
27.8
19.1
8.4
8.2
5.4
3.3
3. I
3. I
2.3
1.8
1.6
I .6
I .4
I .2
I .2
1 .O
5.2
2.5
60,300
77,200
176,500
149,300
28,000
53,500
67,500
123,200
15,050
187,400
26,957
83,900
-
I .9
8.8
5.0
5.6
5.6
9.4
11.3
9.4
8.8
13.1
13.0
9.7
11.3
13.1
10.6
23.8
50
-
-
population figures not available.
ized.” Whereas specialists account for 73.8% of all
physicians in the United States, this figure is 77.9% for
Orange County and 91.4% for Newport Beach (6).
Rheumatologists account for 0.8% of physicians in the United States. In 1975, rheumatologists
comprised 0.4% of Orange County and Newport
Beach physicians.
However, to the extent that data concerning
one rheumatology practice can be useful, the following
conclusions were drawn from the first I ,OOO patients.
The private practice of consultative rheumatology can be both stimulating and academically challenging, with its fair share of unusual cases. Degenerative joint disease accounted for a relatively small
proportion of patients (21 .l%), whereas 70.8% of
patients fell into the categories of inflammatory arthritides and connective tissue disorders. Adequate representation was noted in a wide spectrum of diagnostic
categories, including lupus erythematosus, scleroderma, polymyositis and dermatomyositis, Felty ’s syndrome, polymyalgia rheumatica, Sjogren’s syndrome,
sarcoidosis, and Henoch-Schonlein purpura.
The major referral sources for the rheumatologist were internists and general practitioners, together
accounting for 48.9% of all referrals. Orthopedic surgeons referred 9.5% of our patients. The Arthritis
Foundation chapter referred only 4.9%, suggesting
that the latter may be an underutilized community
resource by many arthritics. Overflow patients from
another rheumatologist approximately 10 miles away
constituted only 1.2% of patients. This relatively small
number of referrals from a busy rheumatologist in
practice for 8-10 years, with a waiting list of perhaps 3
months or more, suggests the reluctance of patients to
leave their immediate geographic setting for a medical
appointment.
Patients referred by friends (4.7%) and relatives
(2.7%) were initially a relatively minor part of the
referral patterns. However, as the practice increased,
so did the number of referrals from satisfied patients.
This trend continued as additional rheumatologists
moved into Orange County and Newport Beach. By
1980, the number of such patient-to-patient referrals
had more than doubled to approximately 20%.
Although a few patients traveled long distances
for their rheumatologic care, the vast majority of
patients were confined to a rather narrow geographic
circle. Over 80% of patients were referred from an
area within a radius of approximately 10-15 miles,
representing a combined population of 777,507. Over
50% of all patients referred came from the immediately
contiguous communities of Newport Beach, Costa
Mesa, and Irvine, with a total population of 165,000. It
would appear that a population of 150,000-200,000
within the geographic confines of a 10-15-mile radius
would be of appropriate size to support a new and
developing rheumatologic consultative practice. Given
a prevalence figure of 6.4% for arthritis and rheumatism (7), this would represent a population of approximately 12,000 patients with some form of arthritis, of
which perhaps 10% or less are being referred by their
primary care physicians for rheumatologic care.
These figures are consistent with sociologic
surveys, which estimate that 19% of people with
arthritis have never seen a physician. Only 42% were
under medical care when interviewed (7), and even
fewer ever reach a rheumatologist’s office.
In an environment where rheumatologic services are needed and where a reasonably sophisticated
medical community exists willing to refer such patients, a purely consultative rheumatologic practice is
entirely feasible from the first day, without the need to
accept general medicine patients just to keep busy. No
substantial lag period was apparent in the early stages
of practice, and the referral patterns were such that an
average of 2 new patients per working day was a
reliable and consistent expectation. This number was
not significantly influenced by the subsequent influx of
additional rheumatologists into the area.
Two reasons may explain the lack of impact of
new rheumatologists. I) New rheumatologists did take
away certain physician referral patterns that had previously existed, but this decrease seemed to be offset by
PRIVATE PRACTICE OF RHEUMATOLOGY
the increased patient-to-patient referrals that developed as a function of time. 2) The geographic radius
for referrals progressively widened as people in outlying areas became more familiar with my work and
name recognition improved.
However, the newer rheumatologists found that
their practices started more slowly, until their own
patient-to-patient referrals increased and until their
name recognition in the more remote areas improved
so that referrals from these sources became significant. Consequently, it would appear that, whereas a
population base of 150,000-200,000 within a radius of
10-15 miles would be appropriate to a newly established rheumatologic practice for the first rheumatologist, such a base might not be adequate for the second
rheumatologist on the scene, and perhaps less and less
adequate for subsequent rheumatologists entering the
area.
The nucleus of an office practice in rheumatology consists of patients with chronic inflammatory
arthritic disorders such as rheumatoid arthritis, rheumatoid variant disorders, and connective tissue disorders such as lupus erythematosus, scleroderma, and
others. The average followup period for patients with
inflammatory and connective tissue disorders was 18.2
weeks, as compared to 7.4 weeks for patients with
degenerative joint disease and related disorders.
Patients with osteoarthritis, bursitis, and tendinitis rarely became chronic patients. Some patients
with osteoarthritis became discouraged with the lack
of significant long-term benefit from medications and
physiotherapy. Patients with bursitis and tendinitis,
however, generally improved quickly so that they no
longer required on-going rheumatologic care.
Not infrequently, patients with rheumatoid arthritis, lupus erythematosus, scleroderma, and other
inflammatory and connective tissue disorders became
the primary care patients, with most of their medical
services being supplied by the rheumatologist. Approximately 38% of patients with rheumatoid arthritis
became such primary care patients, and the numbers
were even greater for lupus erythematosus patients
(75%), scleroderma (70%),and polymyositis/dermatomyositis (90%).
The influence of folk medicine and quack medicine remained significant and pervasive within the
community. A number of patients were seen who had
either relied heavily on such measures, often with
unfortunate results, or who regularly became tempted
1307
whenever a new miracle cure was reported to them.
Patient education in general was inadequate, and the
channels for communication and information, such as
the Arthritis Foundation, were often underutilized by
the public.
Although the experiences of one rheumatologist
cannot necessarily be generalized to others, the following guidelines may be helpful for the rheumatologist-in-training who is contemplating a consultative
referral practice in the private sector:
1. Interesting patients will be plentiful. Perhaps a full
75% of cases can be categorized as inflammatory and
connective tissue disorders.
2. Nearly half of all referrals will probably come
from internists and general practitioners.
3. There may be a rather narrow geographic radius of
perhaps 10-15 miles that will comprise the sphere of
influence in terms of referrals.
4. A population base of perhaps 200,000 people may
be necessary to support a referral practice in rheumatology. Although the prevalence of arthritis in the
general population is 6.496, less than half of these are
seeing a physician, and perhaps 10% of this group will
be referred to a rheumatologist.
5. As additional rheumatologists move into the area,
the number of patients referred may not be significantly affected, although the patterns of referrals tend to
change, with more patient-to-patient referrals replacing lost physician referrals.
REFERENCES
1. Sucgang FP: My medical practice. Nebr Med J 60:104-
105, 1975
2. Menchez S: Private Practice in Britain. London, Bell.
1967, pp 1-95
3. Nourse AE, Marks G: The Management of a Medical
Practice. Philadelphia, Lippincott, 1963, pp 1-387
4. Henke CJ, Epstein WV: The training of United States
rheumatologists, 1927-1976: description and evaluation
of the training experience. Arthritis Rheum 22:182-185,
1979
5. Samuelson CO Jr, Cockayne TW, Williams HI: Current
comment: rheumatology: what students should know.
Arthritis Rheum 22:290-293, 1979
6. Orange County Medical Association Bulletin, 1974, pp
3-4
7. Health Statistics, Series B, No. 20, U.S. Dept. of Health,
Education, and Welfare, 1960. (Arthritis and Kheumatism)
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