More than 2 million Americans with Rheumatoid Arthritis are caught in the middle of a debate among physicians over which treatment – medications or hand surgery – will help their ravaged fingers and wrists most.
And a new University of Michigan Health System study finds that entrenched attitudes and lack of communication among Rheumatologists and Hand Surgeons, and a scarcity of data comparing the two strategies, are keeping the controversy going.
Only large studies evaluating the effectiveness of various hand operations, the researchers say, will quell the debate and help patients get consistent and beneficial care no matter what kind of doctor they see or where they live.
Amy Alderman, M.D., M.P.H., lead author and her U-M colleagues – who include a rheumatologist, a senior hand surgeon, general internists and a statistician – surveyed nearly 1,000 doctors selected by random sampling from among the members of top rheumatology and hand surgery societies.
“We see dramatic differences of opinion and practice over an important clinical problem that will only increase in importance as the population grows older,” says co-author Peter Ubel, M.D., associate professor of internal medicine and psychology. “We don’t know yet what will work best for individual patients, and so physicians don’t agree about the best way to treat this condition. Patients need to be aware of this, and they may need to talk to several doctors to decide what’s right for them.”
Medications have long been used to reduce inflammation, and work for many patients for years after diagnosis. But hand surgery has been seen as an option for patients who do not respond to medicines or whose hands have become so twisted and contorted that they no longer work.
In the newly published paper, 70 percent of the rheumatologists surveyed considered hand surgeons deficient in their understanding of the non-surgical treatment options for rheumatoid arthritis, while 73.6 percent of the surgeons thought rheumatologists didn’t know enough about the surgical options available to their patients.
The different ‘management concepts’ that rheumatologists and hand surgeons have for rheumatoid arthritis patients are only further divided by the fact that specialists in the two fields tend to read and publish research findings in their own field’s journals, says Alderman.
And, she notes, only small uncontrolled studies have been performed to see how well the different operations work to repair arthritis-damaged hands or prevent more damage. Larger studies, aimed at measuring outcomes for different operations performed at different times, are needed.
At the same time, plenty of such data is available for new medications that have come on the market in recent years – data from the major controlled studies required for drug approval by the U.S. Food and Drug Administration.
As those new medications come into widespread use to help control the damage caused by the inflammation of rheumatoid arthritis and prevent progression of the disease, fewer patients may need early, aggressive surgery that preventively removes joint linings, Alderman notes.
But more may eventually need joint replacement or synovial surgery after medications start losing their effectiveness — and the speed with which they get that surgery may have a lasting impact on how well their hands regain function. That means communication between specialists will become more important than ever.
The U-M Medical School is trying to bridge the gap in cross training, by exposing medical residents in surgery and rheumatology to the other specialty during joint sessions. All in all, say the authors, patients need to ask about all possible treatment options when they see primary care doctors and specialists, and decide what’s right for them based on the level of their symptoms and the response to medications.
The U-M researchers also hope they’ll be able to help gather the data needed to prove surgery’s effectiveness, and the best timing for certain operations. Kevin C. Chung, M.D., M.S., an associate professor of plastic and reconstructive surgery and the hand surgeon in these publications, will be leading a team of international researchers to study outcomes of surgical procedures in the rheumatoid population. These studies will be an important first step to bridge the gap between the two specialties.