Two sides of the Rheumatology Coin

Two sides of the Rheumatology Coin

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Image courtesy of Arvind Balaraman at
Image courtesy of A.Balaraman at FreeDigitalPhotos


By Dr Irwin Lim, Rheumatologist

I was involved with some interesting market research. It involved a “good cop, bad cop” scenario.

I was asked to place myself in the position of a rheumatologist who was strongly advocating the use of biologic medication in a patient with ankylosing spondylitis. I spoke to an empty chair explaining my case.

The imaginary patient was, for this scenario, very nervous about the medication, because she had a very strong family history of multiple sclerosis (this is a complicated situation given some case reports of multiple sclerosis on TNF-inhibitor therapy).

My case was strong, and I put it forward reasonably confidently. The benefits outweighed the risks, quite clearly.

Next, I was asked to move to the empty chair.

This time, I was asked to play the role of a rheumatologist who was not an advocate of using biologic medication in this same hypothetical patient.

This was a harder role to play.

Why would I wait and work on alternative measures, eventhough I believed these were going to be less effective? The argument was based around the angst such a decision would cause this patient, and how her perception of risk was so great that it would be better to err on the side of caution to give her peace of mind.

After this role playing, I was asked to describe my behaviour as a rheumatologist in the 2 scenarios in 1 word.

Again, I found this hard to do. I chose the words, paternalistic vs patient-centred.

I’m not quite sure if they were the right words. And I’m not quite sure of the point of the exercise. But it provided food for thought.

Everyday, I think rheumatologists play either role depending on the different scenarios which unfold in our consulting rooms.

Do you agree?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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