Many different health conditions are associated with aging: Cataracts, diabetes, hypertension and dementia, for example, become increasingly common with age. Perhaps the condition most closely associated with moving on in years is osteoarthritis, a very common disease that results from a breakdown of joint cartilage and bone. This can lead to swollen, stiff and painful joints that impede normal activities. Virtually every person will develop osteoarthritis if they live long enough — it’s a simple case of wear and tear on the joints over time.
If you’re dealing with osteoarthritis, chances are good your primary care physician can help you manage the disease. But if you develop complications or have an especially severe case of this very common ailment, you may need the assistance of a specialist doctor who treats rheumatic disease — a rheumatologist.
But there’s more to rheumatology than just arthritis. Although osteoarthritis is the most common complaint rheumatologists treat, there are a wide range of so-called rheumatic diseases that a rheumatologist can help with.
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The term rheumatic disease refers to a collection of about 100 diseases that feature inflammation of the connecting or supporting structures of the body, such as joints, tendons, ligaments, bones and muscles. Rheumatoid arthritis, fibromyalgia and gout are rheumatic diseases. Certain autoimmune disorders, such as Sjögren’s syndrome and lupus, are also considered rheumatic diseases. The specialist who can help you cope with this wide range of sometimes very complicated conditions is the rheumatologist.
The American College of Rheumatology reports that “a rheumatologist is an internist or pediatrician who received further training in the diagnosis (detection) and treatment of musculoskeletal disease and systemic autoimmune conditions commonly referred to as rheumatic diseases. These diseases can affect the joints, muscles, and bones causing pain, swelling, stiffness, and deformity.” Typically, a rheumatologist completes medical school and residency in internal medicine or pediatrics followed by a two or three-year fellowship in the subspecialty of rheumatology.
In finding the right doctor for your specific situation, you may have some challenges ahead, given that the ACR recently sounded the alarm over a coming shortage of physicians in the field. But it’s important to find a doctor with whom you’re comfortable, because you may be working with this person for the rest of your life; rheumatic diseases tend to be chronic ailments that require ongoing management.
When searching for the right doctor for your needs, Dr. Thomas Olenginski, a rheumatologist with Geisinger in Danville, Pennsylvania, says “the patient’s best resource is the doctor or medical team they’re seeing.” Ask your primary care physician for a referral, and find out who’s respected locally.
In assessing which doctor to see, Olenginski says there’s simply no substitute for experience. “You cannot underappreciate the importance of experience, because sometimes in our realm we’re asked to identify very unusual conditions we’ve only seen a few times. Sometimes it can take decades to see unusual things a few times.” He says he’s a better doctor today “than I was a year ago only because I’ve had experience and time to reflect and learn.”
Accessibility is another important aspect of finding the right doctor. “I commonly hear that someone has had to wait three to four months” for an appointment, Olenginski says. I saw someone yesterday who was referred to a different physician but couldn’t get in until December. I think accessibility is very important and the ability to develop a way to see people quickly, even when a practice is busy,” is important to providing patients with good care.
Before heading to the first appointment with a rheumatologist, there are a few things you can do to help make that meeting be as productive as possible. Dr. Wael Jarjour, professor of medicine and division director of immunology and rheumatology at The Ohio State University Wexner Medical Center in Columbus, says being aware of when symptoms began can be a big help in figuring out the right diagnosis and best course of treatment. “It doesn’t have to be the specific day, but roughly when certain things occurred, that’s very useful.” If your doctor provides a questionnaire to fill out prior to the appointment, that can also help guide the conversation in an initial meeting and get to answers faster. “Those questionnaires are very useful and a good starting point for the discussion in the appointment to learn about the history of the illness,” he says.
[See: 14 Things You Didn’t Know About Nurses.]
Also making sure all previous records have been received by the rheumatologist’s office ahead of your appointment can help facilitate a diagnosis while eliminating unnecessary or duplicate testing, Olenginski says. “For patients coming from outside [the Geisinger system] where there’s no connectivity to our medical records, I like to receive office notes and any testing and actual X-rays that have been used. They facilitate a more expeditious evaluation and reduce the need to unnecessarily order and duplicate tests. I don’t like to order tests when I don’t have to.”
Jarjour says it also helps if the patient has a clear understanding of the specific question they’re being referred to the rheumatologist to answer. “When a primary care or another specialist refers a patient to a rheumatologist, it’s very helpful for the referring doctor to tell the patient, ‘I’m referring you to this doctor for this specific question to see if they can help us with that.’ Sometimes the patient doesn’t know why they’re being referred,” so if the referring doctor hasn’t made that clear, be sure to ask.
With many rheumatic diseases, arriving at a correct diagnosis can take some time. Many different conditions can cause symptoms that mimic each other, so unraveling exactly what’s causing the problem sometimes requires intensive detective work. But Olenginski says most rheumatologists are “comfortable with diagnostic uncertainty. Patients don’t always leave with an absolute diagnosis. It can be many things that can be related to new patient signs and symptoms, so it might take a while to really define.” But an experienced rheumatologist can puzzle through the various inputs to arrive at the right diagnosis faster than a less experienced doctor, Olenginski says.
Tolerance of uncertainty and a willingness to collaborate with other experienced rheumatologists are both hallmarks of a good rheumatologist, Olenginski says. “The ability to be honest and say, ‘look, we’ve looked at you and we think it’s this condition but because of the nuances, I want to get another opinion from someone I know and respect,’ that’s going to help everybody,” he says.
Olenginski also recommends talking with your rheumatologist about other doctors you can see if you need to do so when you’re in another part of the country. Because rheumatic diseases tend to be more common among older adults who may be retired and spend the winter in warmer climates, it’s helpful if you can have a local doctor who will collaborate with your regular rheumatologist if you need to be seen physically while away from home.
Developing the right management plan for some rheumatic diseases may also require some patience on the part of patients, as it may take some trial and error to arrive at the appropriate treatment protocol. But specifically for diseases like lupus, rheumatoid arthritis and fibromyalgia, newer treatments are offering better outcomes for patients, Jarjour says. “Treatment for autoimmune diseases largely depends on suppressing the immune system. So, we used to do that in a very broad way that actually was associated with significant side effects and toxicity for the patient. Nowadays we have a lot more targeted therapies that really work a lot better than some of the old drugs we used to have. We can treat patients, for example, with rheumatoid arthritis with drugs that help them significantly in making their disease go into remission while also improving their function substantially.”
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
Although the noted shortage of rheumatologists, which is more severe in some parts of the country than others, may limit the number of options you have, it’s still important to think about whether you think your doctor understands your condition and whether the rheumatologist you’re seeing is the right fit for you. “I think the most important element is to be a good listener,” Jarjour says. “Listen to your patients as they talk and try to understand what their history is and what brings them to see you.”
He says skill when conducting physical examinations can also be a big help in determining the correct diagnosis. “In many specialties, we depend significantly on our ability to find abnormalities on a physical exam that lead us to arrive at the correct diagnosis.”
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