We read with interest the recent report by Shan et al.1 on the utility to an Australian tertiary public rheumatology service of an in-house rheumatologist triaging all general practitioner (GP) referrals and diverting to an outpatient general medical service for initial clinical assessment and management of all those deemed to have a low probability of inflammatory or autoimmune rheumatic disease. In particular, we note that all (four) GP-referred patients with suspected fibromyalgia were diverted to the general medical service and all (11) patients subsequently diagnosed with fibromyalgia by this general service appear to have been promptly discharged on the basis that the rheumatology and general medicine physicians involved considered fibromyalgia to be a benign disorder. We acknowledge the clinical load pressures under which public ambulatory rheumatology services operate in Australia, and that within the tertiary hospital setting, rheumatology services frequently define themselves as treating inflammatory/autoimmune rheumatic diseases alone. However, it needs to be recognised that an expanding literature confirms that the frequently occurring and multidimensional syndrome of fibromyalgia2 is likely to be at least equally the most debilitating and disabling of all non-lethal rheumatic diseases, resulting in potentially severely impaired health-related quality of life.3-5 Furthermore, when comorbid with other rheumatic diseases, the health-related quality of life of these patients is majorly worsened.6 Moreover, among other consequences, chronic widespread pain and fibromyalgia are associated with a significantly increased risk of developing Alzheimer disease,7 and suicidal ideation and potentially suicide attempt rates among those with fibromyalgia are likely the highest of all those with rheumatic diseases.8 For optimal management, fibromyalgia needs to be carefully discriminated clinically as either primary (presumed to be a top-down neurophysiological disorder) or secondary (presumed to be a bottom-up disorder but can be comorbid with primary fibromyalgia processes),9 skills which are not necessarily possessed by Australian GPs. Primary fibromyalgia is increasingly recognised internationally as best managed within multidisciplinary primary care, with rheumatologists providing secondary-level support upon request.10 However, the current structure of Medicare continues to make comprehensive supportive management of primary fibromyalgia in Australian general practice very challenging. Australian tertiary hospital public rheumatology clinics clearly have no capacity to contribute to such a model of care for primary fibromyalgia other than to make the diagnosis and discharge to primary care. A problem, however, arises with tertiary clinical services needing to manage effectively the high frequency of secondary/comorbid fibromyalgia, which occurs with patients with inflammatory/non-inflammatory rheumatic disease under their care.11, 12 Tertiary-level specialists therefore need to have the clinical skills to diagnose primary and secondary fibromyalgia accurately, appreciate the significance of these disorders to afflicted patients and understand how to manage these conditions optimally within the healthcare system they operate. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
Kwiatek et al. (Wed,) studied this question.