Why You Should Be Seeing A Rheumatologist

Posted on 18 February 2010

Your primary care provider (PCP) may be a terrific doctor, but is he/she the right person to be treating your arthritis? Many arthritic diseases (and certainly rheumatoid arthritis) are systemic, difficult to manage and sometimes even life threatening. Here’s why you deserve to be seen by a rheumatologist.

Is your doctor a board certified rheumatologist? If not, you might be cheating yourself out of the care you deserve. Ask yourself this question: if you had cancer, would you see a family practitioner or an oncologist? That may sound extreme, but if not treated properly, RA can potentially be fatal. So, while your PCP may the ideal doctor to maintain your general health, a disease as complex as rheumatoid arthritis needs to be treated by a specialist.

A Rheuma-who?

According to the American College of Rheumatology (ACR), a rheumatologist is “an internist or pediatrician who is qualified by additional training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Furthermore, many rheumatologists also conduct research to determine the cause and better treatments for these disabling and sometimes fatal diseases.” And if you have experienced persistent pain in your joints, muscles or connective tissues—especially if symptoms persist for six weeks or longer—a rheumatologist is the doctor you should see.

It is estimated that there are over 100 different types of arthritic diseases (some say as many as 175). Anything ranging from infection to cancer can look like or be involved with joint pain. While all doctors study rheumatic conditions, it would be impossible for the average PCP to stay current on all the different types of diseases and treatments. Even if your PCP is a top-notch physician, he/she can not measure up to the educational standards of a rheumatologist:

* Four years medical school (internal medicine or pediatrics)
* 2-3 years specialized rheumatology training in the rheumatology department of a working hospital
* Since most rheumatologists choose to become certified, they must pass a rigorous exam conducted by the American Board of Internal Medicine
* Many rheumatologists also participate in regular continuing education programs

And rheumatologists aren’t limited to treating the more than 100 different types of arthritis. They also treat certain autoimmune diseases such as lupus, back pain, osteoporosis, musculoskeletal pain disorders such as fibromyalgia, and tendonitis. Their education and experience allow them to accurately evaluate symptoms and determine the correct diagnosis. The importance of early diagnosis in arthritic conditions (particularly RA) has been proven, but often symptoms are difficult for the average doctor to diagnose.

For example, if a patient is suspected of having RA, most doctors will routinely test their blood for presence of the rheumatoid factor. However, it is estimated that 25% of people with rheumatoid arthritis are known as seronegative and will never develop the rheumatoid factor. Moreover, the rheumatoid factor has also been found in people with other autoimmune diseases, such as lupus, mononucleosis and even leukemia. So how can a doctor really know whether a patient has RA or some other condition?

A rheumatologist will be able to tell because he/she has been specially trained to correctly analyze specific blood tests. He has also been trained to take a complete medical history, to give the patient a comprehensive physical exam, and what to look for when viewing diagnostic x-rays. After carefully listening to the patient and analyzing the data, a rheumatologist will be able to pinpoint certain patterns of symptoms that another doctor might overlook. Once he/she diagnoses the disease, an individualized treatment plan will be prescribed.

Brave New World

We are fortunate that—if we must have arthritis—this is the time to have it. In the past few decades, many RA patients were treated with little more than aspirin and Prednisone. We still have aspirin and Prednisone, but now we also have NSAIDS, COX-II inhibitors like Celebrex, disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate and Arava and the new biologic agents, Enbrel and Remicaide. Yet recently, I met a woman who had been diagnosed with rheumatoid arthritis and her family practitioner had prescribed only naproxen. She was in a great deal of pain, but accepted it because her doctor had told her, “You’re just going to have to learn to live with pain.”

Since rheumatologists recognize that treatments of arthritic conditions are changing (and improving) rapidly, many of them participate in ongoing educational programs to be as current as possible. Just a few years ago, even rheumatologists began treating new patients with only NSAIDs and maybe Plaquenil. If his or her symptoms did not improve, then they might try corticosteroids and DMARDs. Now, however, many rheumatologists believe in more aggressive treatment, often starting a patient on a DMARD like methotrexate and then escalating to “combination therapy” (e.g. biologic agent such as Remicaide in combination with a DMARD) if they don’t respond. This new, “aggressive” approach minimizes the chance for deformity, disability and lessens the severity of the symptoms. In rare cases, it could possibly bring about spontaneous remission.

These drugs are not without risks, however, and your rheumatologist is the most qualified doctor to monitor these drugs for possible side effects or drug interactions. He or she is also well versed in other forms of treatment, such as the use of heat/ice, exercises and orthotics and can provide referrals to appropriate professionals or agencies. If asked, he/she can even refer some patients to clinical trials. Often, patients don’t mind being a “guinea pig” if there is a chance of lessening their symptoms.

Someone once told me, “You have completed successful rheumatology training when you can look patients in the eye and say ‘I don’t know’”.

Steven S. Overman, M.D.

“I Can’t See a Rheumatologist Because…

Still, only a minority of RA patients see a rheumatologist. Many people are under the misconception that they can’t afford a rheumatologist. And it’s true—a specialist does charge more money than a family practitioner. In the long run, however, a rheumatologist could actually help you save money. A rheumatologist saves you money by:

* Diagnosing your condition more quickly
By diagnosing your condition/disease more quickly than a PCP, you are able to avoid unnecessary blood tests, office visits and second or third opinions.
* Specially tailoring your treatment
By pinpointing which treatment is best for you, you save money on unnecessary and possibly ineffective treatments.
* Reducing the severity of your symptoms
Which could lead to you keeping or attaining employment; it also prevents the kind of deformities that could lead to permanent disability.

But sometimes seeing a rheumatologist is easier said than done. Unfortunately, there are thousands more people with arthritis than there are rheumatologists and the rheumatologists out there are spread pretty thin. I drive 90 miles round-trip to see my rheumatologist…and consider myself lucky. Often, people (especially in rural areas) live hundreds of miles away from a qualified rheumatologist…and if they felt well enough to drive hundreds of miles, they probably wouldn’t need a rheumatologist. Still, one might be closer than you think. If you would like help in locating a certified rheumatologist, ACR offers a Geographic Membership Directory.

So, you found a rheumatologist, but your insurance won’t pay for a specialist? Fight. You heard me—fight them and don’t give up until you get a satisfactory answer. You are entitled to appeal any decision that you feel is unfair. If you have exhausted all of your appeals and you still haven’t found satisfaction, contact you state insurance commissioner. You’d be surprised how a call from the insurance commissioner can lead to results. In the meantime, there are other sources of financial aid. ACR lists several sources of Assistance . Don’t let pride stand in the way of your health!

But My Doctor’s So Nice!

Sure he is…but he is also a professional and should be able to recognize his limitations. According to a study published by the Journal of American Medical Association (JAMA), 1355 patients with RA were followed for 3.9 years. 45%-60% were treated by a family practitioner, while rheumatologists treated the remaining patients. Researchers found that the quality of care for those patients without rheumatologists was insufficient. However, the family practitioners were superior to the rheumatologists in providing basic health maintenance.

In other words, this isn’t about firing your doctor. Ideally, your rheumatologist and your PCP should work as a team, consulting each other whenever there is a question or a problem. Nowadays, most PCPs will automatically refer any patient with an arthritic condition to a rheumatologist, anyway (assuming availability). And if he/she is offended by the suggestion, you not only need a rheumatologist, you need a new PCP…someone with a sounder self-esteem.

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