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The Internist’s Role in Treating Fibromyalgia & Chronic Fatigue Syndrome?

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Editor's notes: 1) We are saddened to report that Dr. Robinson passed away in September 2004.

2) While there is no question that a combination of alternative and traditional therapies – holistic medicine approaches, benefit most patients, the following article is of interest since it was written by a doctor who has FM – who happens to be an internist.

By Deborah F. Robinson, M.D.

Internal Medicine is the intellectual branch of medical science, the Sherlock Holmes sleuthing of strange presentations for common and uncommon diseases. It is also the treatment of chronic medical conditions for which there is no cure but merely "management." These typically include hypertension, hyperlipidemia, diabetes mellitus, degenerative arthritis, congestive heart failure, chronic pulmonary disease, renal disease, cerebrovascular disease, degenerative and rheumatoid arthritis, and even depression.

Although there are specialists who treat each of these conditions, they usually train in internal medicine first then "subspecialize" in these fields. But for many patients, an internist is their primary care provider and the only physician they see for these conditions. Internal medicine specialists, "pediatricians for adults," deal with more complicated issues than typically face family practice specialists.

Internists often have to know about and prescribe a great variety of medications to stabilize and improve the quality and quantity of life for an individual, without causing untoward side effects or drug interactions or toxicities. The internist is thus the first and usually only specialist best suited to evaluate, diagnose and effectively treat the conditions of fibromyalgia and Chronic Fatigue Syndrome (CFS).

In the past, rheumatologists were thought to be the likely choice. After all, patients complained of diffuse body aches including muscles and joints, a venue usually covered in rheumatology. However, with advancing knowledge of fibromyalgia (or "fibrositis," as it was first called), came the realization that there was no "-itis" or inflammation involved, and rheumatologists, who are now in somewhat short supply since their residency programs are not being funded, are unable to work with non-arthritic conditions.

Thus it returns to the internist to treat the extremely common condition known as fibromyalgia (affecting some 2% of the population) and perhaps the complex devastating illness known as CFS.

However, the internist should understand fibromyalgia's "systemic" quality, which affects not just achy muscles or tiredness, but also many body malfunctions such as IBS (irritable bowel syndrome), migraine, endometriosis, allergy/asthma, depression, cardiac arrhythmia, autonomic dysfunction syndromes including NMH (neurally mediated hypotension) or POTS (postural orthostatic tachycardia syndrome), spastic bladder, multiple chemical sensitivities, hypothalamic-pituitary-adrenal axis dysfunction, and immunological imbalances.

This is an ideal arena for internists, since they thrive on challenge, sleuthing out physiological processes, ruling out causes of illness common and uncommon, and treating complicated multi-organ system disease with multiple regimens. Unfortunately, the prevalence of managed care and the pressure to perform with high patient volume and shortened patient visits works against the ability to ferret out multiple symptom and organ system diseases.

Also, one finds prejudice against patients with multiple medications, especially by physicians who don't believe in these conditions, as I am sure the reader well knows. It often remains to FIND an internist dedicated to helping these individuals because of personal links or who is fascinated by the neurochemical theatrics playing out in a human drama. It also remains, if one can find time or energy for advocacy, to work with your insurance company and Medicare/Medicaid to adequately reimburse your physician for the extra time spent on your behalf.

The internist should be open to first defining the array of symptoms presenting, next ruling out common and often easy-to-treat complaints as well as life-threatening ones or infectious diseases, then categorizing the worst symptoms from greatest pain/disability to least and "attacking" one at a time.

The most important goal: adequate sleep, including enabling all 4 stages of normal sleep and ruling out pathologic nonrefreshing sleep, or stimulation to decrease pathologic prolonged sleep. Next, relieve pain with a wide assortment of different pain modulators, often initially cleared by the FDA for other therapeutics. Third, improve energy, boost thinking/focus, have an exercise plan, counsel on expectations, and encourage patient advocacy with schools, employers, disability panels. Often the physician needs to set limits with patients long burdened with chronic dysfunction, "whining" as it were and wanting a lot of phone or office time. But the patient and physician need to partner in making the patient more functional, more comfortable, more accepting of limitations and more inclined to work on strengths.

As a board member of OFFER (Organization for Fatigue and Fibromyalgia Education and Research), I am hopeful that we can educate and excite other internal medicine physicians, as well as other providers, to learn about and take on the challenge and reward of helping patients manage fibromyalgia and CFS.

Author's biographical statement: I am an Internist, certified by the American Board of Internal Medicine, and I have been practicing general internal medicine for 24 years in Salt Lake City. I moved to Salt Lake City, the original home of my parents, while still in high school and I attended the University of Utah as an undergraduate and for medical school. I did a straight internship and residency at LDS Hospital in internal medicine.

I have been involved in teaching medical students, interns and residents during my career. For a time I served as the medical director of the Utah PMS Center of Salt Lake. I have been active in "political medicine" in my county and state medical societies and I was the first woman president of the Salt Lake County Medical Society. I served as a Utah delegate to the American Medical Association for 6 years. I have been on a number of ad hoc committees for strategic planning of residency training, internal medicine at LDS Hospital, and state planning for medicine in the new century. I have appeared on various talk shows on TV and radio, and addressed both lay and professional audiences on the topics of PMS, menopause, women and heart disease, diet doctors (including speaking at the Governor's Conference on Families).

Approximately ten years ago I went to my first American Association for Chronic Fatigue Syndrome (AACFS ) conference in Tampa, Florida, and began to learn about the diseases now known as fibromyalgia and Chronic Fatigue Syndrome. As happened with PMS, I learned that I too suffered from fibromyalgia and have my own assortment of autoimmune phenomena not yet classified as a specific rheumatologic disease. So I understand the fibromyalgia problem inside and outside. I know of the lay and medical prejudices against these syndromes, and I also know of ways to cope and improve how one feels with it.

Source: The Arthritis Foundation (online at www.arthritis.org)

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