A rheumatologist specializes in diagnosing and treating arthritis and related rheumatic diseases. Many people, when referred to a rheumatologist, feel intimidated. They don't know what to expect from a rheumatologist. They don't understand how a specialist differs from their primary doctor. Simply put, a rheumatologist is a medical doctor who is trained in rheumatology, a sub-specialty of internal medicine. After completing a two-year rheumatology fellowship and becoming board-certified, a rheumatologist is considered an expert in rheumatic diseases. Let's consider, specifically, what you should expect to happen when you consult with a rheumatologist.
It is typical for people who experience early symptoms of arthritis (joint pain, stiffness, and swelling) to initially think that they have sustained an injury. But, when symptoms persist, it becomes necessary to consult with their primary doctor. If the primary doctor suspects arthritis rather than an injury, blood tests and x-rays are usually ordered to support the diagnosis.
The primary doctor can prescribe drug (e.g., NSAIDs or pain medications) and non-drug treatments (e.g., heat or ice, brace, mobility aids) to help control the initial symptoms. If there is any question about the type of arthritis, if symptoms are severe, or if an inflammatory type of arthritis is suspected, the primary doctor typically refers the patient to a rheumatologist.
To determine the type of arthritis, a rheumatologist looks for signs, symptoms, and very specific disease characteristics. A rheumatologist also reviews your medical history, performs a physical examination, and orders more complex blood tests, as well as more imaging studies, if necessary.
Conservative Versus Aggressive Approach to Treatment
Once a rheumatologist is confident with their diagnosis, the next order of business is to formulate a treatment plan which will control pain and other symptoms and slow progression of the disease. Primarily, the goal of treatment is to relieve symptoms and prevent joint damage while preserving joint function and mobility. If you have been diagnosed with a type of arthritis that has systemic effects, it is also the goal of treatment to minimize those effects.
Rheumatologists can take a conservative approach to treatment or a more aggressive approach. Before biologic drugs were developed for the treatment of rheumatoid arthritis and other inflammatory types of arthritis, conservative approaches were more favored. But since the first biologic drug Enbrel (etanercept) became available in 1998, treatment trends have shifted to a more aggressive approach. An aggressive approach refers to using disease modifying drugs and biologics early in the course of the disease. A conservative approach refers to treating symptoms with older, traditional medications (usually DMARDs at lower doses) while delaying the addition of newer biologic drugs.
Periodic Appointments to Monitor Progress
In some cases, a rheumatologist will be consulted on a limited basis, just to confirm a diagnosis or to offer a second opinion regarding treatment. Some patients, especially those with osteoarthritis, will not need to see a rheumatologist on an ongoing basis. They will return to their primary doctor for continuation of care. But most rheumatoid arthritis patients, as well as those with other inflammatory types of arthritis or less common rheumatic diseases, will continue having their progress monitored by a rheumatologist. At each appointment, the rheumatologist will ask about symptoms and look for signs of active synovitis -- and the effectiveness and safety of treatment will be assessed. Patients on certain drugs (e.g., methotrexate or a biologic drug) must have blood work performed periodically to be sure that there is no negative impact from the treatment.
Variability of Disease
Characteristically, arthritis is a variable condition. It is common and expected that patients will experience arthritis flares (periods of intensified symptoms) and periods when symptoms are under control. The fluctuations occur even though a patient is 100% compliant with their treatment. Not only do aches and pains ebb and flow, joints that had not been affected can suddenly become involved. The variable nature of arthritis requires that both the patient and his rheumatologist be watchful for significant changes.
Arthritis is a chronic disease. Over your lifetime, expect things to change. Expect your treatment to change. Be ready to stop treatment or add to your existing treatment regimen, as necessary. Always discuss changes that you notice and concerns that arise with your rheumatologist. Your rheumatologist depends on you to keep him informed, just as you depend on his expertise to guide you through rough water. The relationship between you and your rheumatologist is a partnership.