Barbara Caffery participates in two hospital-based clinics in Toronto, Canada: the University Health Network Multidisciplinary Sjögren’s Syndrome Clinic and the Therapeutic Contact Lens Clinic at Kensington Eye Institute.
One of the most important aspects of patient care is the co-ordination of many health care professionals. Some countries support the use of a single chart for each patient, allowing multiple practitioners to access input from others. In Canada, we have not achieved such fluidity of information. Occasionally, there is an opportunity to work in multi-disciplinary clinics that allow the sharing of perspectives from a variety of care providers.
For twenty years I have had the privilege of working in the University Health Network’s Multidisciplinary Sjögren’s Syndrome Clinic in Toronto, Ontario. Here, patients seeking a diagnosis spend the entire day at the hospital. They are seen by rheumatology, ophthalmology/optometry, otolaryngology and dentistry specialists, and have x-rays and blood work taken.
The benefits to the patient are clear: an exhaustive review of their case and a group of specialists from many disciplines to listen, test and confer. The benefits to each of the practitioners are less well understood; it is remarkable how little we know of each others’ work.
A teaching and learning experience
My favourite days are those when a rheumatology Fellow decides to follow an individual patient through the day. When they arrive in my office I am able to use fluorescein and lissamine green to show them ocular surface dryness. They are always amazed at the immediacy of the observation: no waiting for x-rays or ultrasounds, no bending of joints or palpation, just the live histology right before their eyes. This is the kind of interaction that allows me to appreciate my own ability to observe and grade a clinical condition.
The eye clinic is also a learning experience. Medical students, residents and Fellows are often interested in the Sjögren’s workup. Although the staining observations are old hat for them, they may not be as familiar with the practice of examining dry tongues, and may not fully understand the fatigue and worry that comes with this autoimmune disease.
I also benefit when my colleagues share their perspective with me: I get to learn from their treatment of ocular conditions when they call me into the room to observe a recent trauma emergency or a minor procedure like pterygium removal or conjunctival resection.
The interprofessional teaching and learning flow both ways: I work with bright, eager learners who love to cut and sew, but who also love to teach and answer questions, and are keen to understand optometry’s practical approach to vision correction and management of chronic conditions such as dry eye.
The team meets for an hour before each Sjögren’s clinic, once a month, to review our findings from the previous month. The chart includes X-rays and the results of blood and urine tests, as well as the histopathology report of the minor salivary gland biopsy.
Although review of systems and X-rays is interesting, for me the most interesting part of the review is the rheumatological evaluation, because the mystery lies in the blood work. There are about ten pages of analysis to review, including markers of lupus and rheumatoid arthritis, scleroderma and mixed connective tissue disease. I have learned the value of rheumatoid factor and C reactive protein in RA, ANA and clinical findings in lupus, anti-centromere antibody in scleroderma and anti-ro and -la in Sjögren’s syndrome.
When we review patient management, I realize that rheumatology and optometry have so much in common: both professions deal with chronic disease. We rarely “cure” anything, but work with patients to more appropriately manage their conditions. We are frustrated by the lack of consistency in diagnostic criteria. We mourn the dearth of treatments for our patients. And with that perspective comes wisdom, humility and the discipline to investigate, retest and retest and manage patients with chronic disease.
Beyond diagnosis: managing conditions as a team
Of course it is not simply about diagnosis. “Where do we go from here?” is also an important question. Since our specialty clinic is not geared toward ongoing care, I have taken on the job of following these Sjögren’s patients over time. I see the severe cases every six months, switching from lubricants to steroids, gels to antibiotics as needed. And if there is a step backward in their general health, i.e. a rash on their legs or trouble breathing, I can easily get them back to the rheumatologist for analysis and usually more systemic medications.
To establish and grow this relationship I depend on communication. No matter how tired I am at the end of the day, I report patients’ ocular and general status to their referring rheumatologist. This reputation for reliability means that many rheumatologists refer their severe dry eye patients to me for ocular testing and management.
Making connections in the community
I have been extremely lucky in my collaboration with ophthalmologists and rheumatologists. Although most of us have no chance to work in a clinic with these colleagues in other professions, we can make sure that they know how useful we can be. My advice – connect with related professionals in your community:
- Make sure that your regional corneal specialists know that you fit contact lenses that may help their keratoconus and dry eye patients.
- Contact your local rheumatologists. Remind them of the strong association between dry eye and many rheumatological autoimmune diseases. Tell them that you understand the Sjögren’s syndrome criteria, and are happy to help to diagnose and manage their patients, including Schirmer testing and stain grading.
There are so many ways that we can work with our medical colleagues. Our job is to communicate our knowledge, clinical skills and attitudes to them so that patients flow our way. After that, good care and disciplined reporting are the most important tasks.