The first objective of the rheumatologist will be to keep the natural skills: diagnosis and management of diseases and of painful and functional disorders of the musculo-skeletal apparatus. The core curriculum of UEMS for Continuing Medical Education and Professional Development could be a good objective: a thorough theoretical knowledge must be maintained of anatomy, biochemistry, physiology, biomechanics, pathophysiology of pain, and cellular and molecular biology and genetics relevant to the rheumatic diseases. “The general attitude should be maintaining clinical skills by regular contact with people with musculo-skeletal conditions, the indications and interpretation of imaging technique such as conventional X-rays, CT scans, ultrasonography and radioisotopes techniques in the diagnosis, assessment ans monitoring of the rheumatic diseases”:
-Degenerative disease of the joint and spine.
-Collagen vascular diseases (which must be considered as “rheumatology with systemic disorders” and not “internal diseases with rheumatological symptomes”).
-Bone disease and calcium metabolism disorders, tumours.
-Inflammatory and metabolic arthritis.
Soft tissues (tendons and muscle) and nervous disorders.
-Spine diseases and particularly low-back pain.
In that sense the rheumatologist must keep its place of orchestra director, to maintain close co-operation with profession allied in the nmanagement of rheumatic disorders.
Through these goals, rheumatologist should stay competent to indicate, interpretate and manage explorations: imaging, to avoid the gap between radiologists and rheumatologists and let open the dialogue between practicians, but also bone measurement techniques. We would emphasise the necessary use of ultrasound in clinical practice. This imaging technique has to become a clinical tool, with the economic difficulties of the cost of the equipment.
Rheumatologist must stay performant in technics such as needle aspiration, bone or synovial biopsy, joint injection...at the least to be able to discuss indications.
In therapy, new biological development such as immunotherapy or molecular biology will be a major field of interest to avoid gap between clinical practice and biological tools, without neglecting more classical therapies such as rehabilitation.
The irruption of biomaterials and the development of percutaneous injections will change our way of therapy in a next future, sooner as we could expect, if we take into account the speed of development of biomaterial fabrication in industry project: artificial cartilage, bone replacement...
The rapid growth and ageing of the population will emphasise the necessary development of chronic disease coping and prevention and the sensibilisation of economic and politic deciders (which is one of the goal of Joint and Bone decade. This means that the rheumatologist has to develop the maintaining quality of life, and not only the function. In that sense, development psychological interventions, prevention of pain and depression would be of benefit for rheumatologist. We have to prove that illness considered as benign are important for ageing population in terms of quality of life, but also economic expanses and prevention of severe complications.
Health economics will be a real problem. What is the real benefit of medical or surgical interventions: economic benefit of modyfying drugs such as methotrexate in RA, bisphosponate in osteoporosis, slow acting drug in osteoarthritis? The answer to these questions are crucial. The practical financial costs of treatment vis a vis the cost of surgical interventions are critical to understanding the necessities of prevention and treatment. Epidemiologic and economic studies are important to develop in the next future.
Patients information will be another challenge in term of access to care: what will be the consequences of the non access to appropriate in term of medical responsibility? What are the good answers to people when we cannot give them appropriate care for economic reasons? What are the controls in term of experimental therapy or surgery or new medical developments? All these questions have to be compared to the growing knowledge of the patients with the quantity of informations obtained through the medias and internet, the best but also the worst.
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