Office management of fibromyalgia.

The office management of fibromyalgia (FM) is best determined by two variables: (1) the severity and complexity of each patient's symptoms, and (2) the specialization and interest of the treating physician. Because there are 6 to 10 million Americans with FM, most patient visits will be to the primary care physician. Rheumatologists, physiatrists, and other musculoskeletal specialists must work with primary care physicians to foster the early diagnosis and appropriate treatment of FM. Primary care physicians are faced with enormous challenges in caring for patients with chronic pain disorders like FM. Our managed health care system insists that patient encounters be brief. Specialty referrals are often discouraged. There is little if any reimbursement for patient education. FM treatment is labor-intensive. Therefore, optimal planning and use of precious office time and resources are most important. Rheumatologists should train our primary care colleagues to recognize FM. Many patients still go months or years before this common syndrome is diagnosed. Rheumatologists should also spearhead teaching primary care physicians the basic treatment principles of FM. If the diagnosis is made early, patients with FM in community practice do very well with simple management techniques. As consultants, rheumatologists should confirm the diagnosis of FM and suggest basic FM management. Some primary care providers or other specialists will be fully capable of bypassing this consultation, especially if the patient responds to simple management suggestions. Manpower surveys have not studied the cost-effectiveness of specialty care in FM. Rheumatologists should also assume the responsibility for the management of FM patients who have not responded to basic FM management. Additionally, some rheumatologists may wish to subspecialize in FM, a major career commitment to this perplexing disorder. These situations constitute advanced FM management.