RWGPS Program
Diagnosing and treating arthritis in rural and remote communities—the challenges
(By Dr Carol Cox, RWGPS program, RFDS Queensland Section)
As a GP with the Rural Women’s GP Service (RWGPS) operated by RFDS, I travel to Western Queensland to conduct clinics every 2 months.
The issues for the diagnosis and management of arthritis remain essentially the same for women living in these areas. Most of the time we are relying on core clinical skills involving taking a good history and conducting a thorough physical examination.
Investigations
The routine investigations used in metropolitan practice such as X-rays and blood tests are sometimes more difficult to provide because X-rays are not available in every community and may be performed by trained remote area nurses rather than radiographers. Specialist reporting involves sending the digital X-rays to a larger centre and the report is then unavailable for immediate discussion with the patient. There is therefore usually a time-lag between investigation and result and for more sophisticated imaging, the patient has to travel long distances often involving being away from the community, work and family for several days.
Blood tests can be taken at the time of the consultation but again, transport of the specimens to the pathology laboratory for reporting takes time and adds another layer of complexity. However we are well served by our pathology providers.
Referral to rheumatologist specialist services requires long-distance travel to major centres, appointments are very difficult to get and there is often a very long waiting list. Thankfully, most arthritis can be managed and treated in the primary care setting.
Management
The most common form of arthritis in these communities remains osteoarthritis. The mainstay of management is maintenance of mobility coupled with symptom relief using pain killers.
Allied health services are few and far between in rural communities. Physiotherapists often serve several communities and occupational therapists are more-or- less non-existent! There are some opportunities for therapeutic massage performed by interested locals but this is provided on an ad hoc basis and fluctuates widely. It is often a service provided by partners or friends!
Many communities have no pharmacy, so the supply of prescription medications has to be arranged using Regulation 24 which allows patients to collect all their repeats at the same time, having faxed the prescription to a pharmacy many kilometres distant. The supplies are then posted out or sent on the mail truck—again causing delay between ordering the medication and the patient receiving it.
Despite these challenges, the resilient Queenslanders who live in the bush manage to cope with their arthritis symptoms with surprising tolerance and forbearance and they are a pleasure to serve!
Arthritis in a grazier’s wife
I look after a wonderful 60 year-old with bilateral hip and knee pain who lives and still works hard on a property 10 hours’ drive west of the nearest rheumatologist (who is so busy that new patients wait six months for an appointment in the private sector.) The property has been in serious drought for the past 10 years and my patient is on a motorbike or horse most days helping with feeding and watering stock, inspecting fences and generally lending a hand. She cannot be spared for the minimum of three days that it would take to travel the 20 hour round trip by car and an overnight stay to see a specialist. In any case, she doesn’t want to go!
We manage with pulses of celecoxib for a couple of weeks when she has a flare-up and high-dose paracetamol most of the rest of the time when her hips and knees are very painful. She has learned what aggravates and relieves her pain by long experience.
She has a positive anti-nuclear antibody (ANA) and a positive attitude!
An aunt of the patient had rheumatoid arthritis and used gold injections but my patient doesn’t really want to explore any further tests for autoimmune or connective tissue disease, there is no pharmacy in the nearest town and the physiotherapist comes to a room 2 hours’ drive away once a fortnight.
So what does this mean for the rural arthritis patient?
We must not forget the whole person and their situation in making clinical choices about chronic disease management.
The messages are that we need more general primary care clinicians and allied health community services in small communities- not necessarily specialist services. The specialists should be “saved” for the small numbers of patients who are unable to function without disease modifying drugs.
Our patients often help us in the prioritising of their chronic disease management issues—they are usually very practical and holistic. Costs and access issues can help make decisions in the less severe end of the arthritis spectrum with positive outcomes for our patients.
Further information on RFDS RWGPS program can be found at the following link: http://www.flyingdoctor.org.au/Health-Services/Clinic-Services/Womens-Health/