New modes of practice

The practice of rheumatology needs to adapt to the changing pressures of modern medicine. This review looks at reports of how rheumatologists work and seeks new evidence of how rheumatologists might work in the future.

Surveys of rheumatologist opinion and of outpatient practice show that demand outstrips supply when it comes to care provision. However, differences in case mix will determine which strategies are best to improve care at particular rheumatologic centers. Educating general practitioners by collaborative consultations may help to improve referral patterns when they are inappropriate, but will not allow a reduction in long-term follow-up. Changing the underlying systems of care, and including nonphysicians in care pathways and processes, is a likely route to improvement, and a new way of running "direct access" clinics may prove to be an important step forward. Involving patients in decisions about their treatment is a fashionable objective but is more difficult to achieve than might be imagined.

Service developments to improve rheumatologic care will be specific to local circumstances, but will rest on the introduction of patterns of work that are structured and address the issue of long-term follow-up. Patients' educational needs and decision support systems need a lot more research.