What is a Rheumatologist?
A rheumatologist is a doctor that specializes in rheumatic diseases. Rheumatologists are specialized doctors who have taken additional training and education in order to diagnose and provide treatment for a wide range of musculoskeletal diseases and systemic autoimmune disorders. Rheumatic diseases are often found within a patient’s bones, muscles, or joints. These types of diseases are often responsible for causing patients severe stiffness and pain in more advanced cases. Rheumatic diseases are often associated with causing visibly noticeable symptoms such as swelling and even deformity within some joints such as the end of the fingers.
Rheumatologists are able to diagnose and treat many autoimmune diseases. The most common conditions treated by rheumatologists include rheumatoid arthritis, osteoarthritis, tendinitis, lupus, gout, and chronic back pain. Rheumatologists are also known to spend significant time conducting their own private research in hopes of finding the causes of these autoimmune diseases or better treatment options. These autoimmune conditions are caused by a person’s own immune system. The immune system can sometimes send inflammation to a certain region or joint within a patient’s body even when the inflammation in those areas are not needed. This influx of unnecessary inflammation in certain areas of the body can cause damage and other symptoms most commonly in a patient’s joints, bones, or muscles. This autoimmunity condition can also affect other areas of the body including a patient’s skin, eyes, internal organs, and nervous systems.
Rheumatologists typically diagnose and treat their patients in an outpatient clinic setting. Most patients are often referred to a rheumatologist by their primary care provider or other physicians for diagnosis and treatment. Many rheumatologists often require patients to have a referral from another physician before an appointment for evaluation can be set up, but some rheumatologists do not require a patient to have a referral for evaluation. Typically, rheumatologists are associated with a hospital or clinic and are expected to evaluate patients hospitalized for any rheumatic related disease.
A Short History of Rheumatology
Rheumatology originated in the year of 1925 at a European meeting of medical hydrology. This is when Jan van Breeman founded the International Committee on Rheumatism. Soon after various other European nations started following in Jan van Breeman’s footsteps and started establishing committees on rheumatism.
Following a meeting with leaders of the European committees, Luis B Wilson of the Mayo Foundation decided to form similar committees of rheumatology in the United States. Around 1928 a group of physicians held a meeting in Philadelphia under the leadership of Ralph Pemberton and established a group name the American Committee for the Control of Rheumatism (ACCR). This group was formed under the expressed purpose to stimulate interest in arthritis education and research. The ACCR spent years setting up exhibits for physician’s education on arthritis at the annual meetings of the American Medical Association.
About nine years later the American Committee for the Control of Rheumatism decided to change their name to a more simplified name of the American Rheumatism Association (ARA). Most of the early work done by the newly named American Rheumatism Association was primarily focused on classifying the different rheumatic diseases with consideration to different factor that could play a part in these diseases. The group also focused on important topics such as differential diagnosis in addition to medical and orthopedic treatments for patients with rheumatic disease.
During the efforts of education by the American Rheumatism Association actual clinical rheumatology was beginning to grow in the United States. Orthopedists were actually the ones that began both non-surgical and surgical treatment of arthritis early in the 20th century thus pioneering the treatment of arthritis. The Mayo Clinic soon sparked the beginning of modern rheumatology by appointing the first rheumatologist. Dr. Hench began his new rheumatology services in 1926.
Dr. Hench started services that provided care for patients with chronic arthritis and also provided an inpatient rheumatology unit. Between the years of 1928 and 1929, Hench traveled to Europe to expand his knowledge of rheumatic disease by spending time with rheumatologists in Europe, the birthplace of rheumatology. For nearly 10 years Dr. Hench was the only rheumatologist at Mayo but was later joined by Charles H. Slocumb, MD in 1935.
Dr. Hench and Dr. Slocumb started working together and began encouraging other physicians to help them compile important rheumatology reviews. The annual Rheumatism Reviews to which Dr. Hench was chief editor became nationally important. This rheumatology program put together by Dr. Hench served as a training program for other physicians and became the only location in the nation where physicians could receive training in rheumatology.
In the year of 1950, Dr. Hench and the mayo clinic was awarded the Nobel Prize for Physiology or Medicine due to a significant discovery. In 1948 the Mayo group and Dr. Hench discovered that adrenocorticotropic hormones and cortisone made significant improvements in arthritis. Patients were experiencing a marked reduction in the inflammation effect in rheumatoid arthritis. This discovery changed American medicine and the way arthritis is treated. By 1960 Dr. Hench had trained nearly 10% of all rheumatologists and later served a term as the president of the American Rheumatism Association.
How common are rheumatic disease and who is susceptible to these diseases?
It is estimated that by the year 2020 there is expected to be 60 million Americans that suffer from some form of arthritis or a rheumatic disease. That estimation is approximately 14 million higher than current Americans suffering from rheumatic conditions or arthritis. This constant growth in rheumatic diseases is contributed to the fact that these diseases can develop in anyone regardless of sex, age, or race.
There are also many different forms of rheumatic conditions and disease that some people can be more susceptible to than others. Susceptibility factors include a person’s genetics, gender, age, and even environmental factors. The highest risk of developing any form of a rheumatic disease is often associated with women, African American, Hispanics, and anyone that genetically carries the PTPN22 gene.
What are the most common types of rheumatic diseases treated by rheumatologists?
Osteoarthritis is by far the most common form of rheumatic disease treated by rheumatologists today. There have been an estimated 27 million cases in adults just within the United States. This single form of arthritis makes up just a little over 55% of all rheumatic cases in America. Osteoarthritis is a chronic form of the rheumatic disease and can be characterized by the gradual breakdown of cartilage in between joints. This cartilage is important for proper joint function because it acts as a cushion. This cushion is in place at each end of the bone which allows joints to move easily without causing any pain. Once Osteoarthritis begins to take effect on a person’s cartilage and begins to break down the cartilage the ends of the bones at that particular joint will begin to rub against each other because there is no longer a cushion. This breakdown of cartilage can often cause significant stiffness, loss of movement at the joint, and severe pain.
- Rheumatoid Arthritis
Rheumatoid Arthritis also called RA is another common form of rheumatic disease. Rheumatoid Arthritis has been estimated to affect at least 1.3 million people just within the United States. This particular rheumatic disease can also turn into long-term damage to joints which will lead to chronic pain. This condition could eventually lead to loss of function and even permanent disability. Rheumatoid Arthritis can be characterized by inflammation within the synovium or lining of the joints. RA is mostly found to affects joints of the feet or hands. This inflammation frequently occurs simultaneously and equally on both sides of the body. This single characteristic is the distinguishing factor from other rheumatic diseases.
- Psoriatic Arthritis
Psoriatic Arthritis is another somewhat common condition for rheumatologists to treat. This type of arthritis is often characterized by the inflammation it can cause in two different locations. If the inflammation is caused by the joints then it is just called arthritis; however, if the inflammation is on the skin then it is called psoriasis. This condition can also affect the joints around the end of the fingers and/or toes. These changes can lead to visually noticeable changes in a person’s fingernails and toenails.
Gout is another form of arthritis that has affected an estimated 2 million Americans. Gout is a condition in which there are microscopic crystals of uric acid that begin to develop on joints. Typically, Gout is found within the feet but more often found in the big toe. This build-up of crystals can cause severe inflammation, pain, and extreme swelling.
Osteoporosis is a common rheumatic disease that affects the bones. This disease causes the bones of the patient to become fragile over time. Osteoporosis causes the bone mass and density to decrease over the duration of the disease.
- Crohn’s Disease
Crohn’s is another form of rheumatic disease because of the inflammation it causes. Crohn’s disease has become more common and widespread across many demographics. This rheumatic disease causes inflammation within the colon or small intestines. This can cause significant and often debilitating discomfort for suffers and can cause patients to have a lower quality of life.
This condition is characterized by inflammation of the tendons. Often this inflammation is in the tendons that connect muscles to bones. Similar to carpal tunnel this condition develops when certain tendons are injured, overused, or if there has been a prior rheumatic condition. Tendinitis symptoms typically include tenderness, restricted movement, and pain.
How does an appointment with a rheumatologist work?
A patient’s first visit with their rheumatologist will consist of several different components. Considering the complexity of some rheumatic diseases they can often be difficult for a rheumatologist to diagnose; consequently, most rheumatologists require a patient to submit a complete family medical history. A family history of rheumatic diseases can be crucial in a patient’s primary diagnosis and subsequent treatment plan. Rheumatologists will then conduct a complete physical examination to look for symptoms and signs of inflammation within the body and entire musculoskeletal system in a patient.
Following a physical examination and reviewing a patient’s family medical history a rheumatologist may be able to diagnose the patient based on those findings, but may also order additional testing. These additional laboratory tests can include radiographic testing such as x-rays, ultrasounds, MRI or CT scans that will help a rheumatologist identify any musculoskeletal deformities or abnormalities. Another test that rheumatologists may conduct could be bloodwork to help assess extra antibody production or inflammation within the body throughout the bloodstream. Once a rheumatologist has reviewed all of the information pertaining to medical history, physical examination, and any additional testing results they will be able to provide a personalized treatment plan. There are some rheumatic diseases however that are difficult to diagnose that may require some follow-up visits with a rheumatologist in order to correctly diagnose a condition.
What kind of treatment plans can a rheumatologist provide?
Treatment plans often vary from patient to patient but could include a variety of methods or combination of methods for treatment. The most common form of treatment that rheumatologists will provide to patients are prescriptions for medications that will reduce inflammation and pain caused by rheumatic diseases. Another common form of treatment for certain rheumatic diseases is a referral by a rheumatologist to a physical therapist. Physical therapy can often time be painful for patients depending on which rheumatic condition they have been diagnosed with, but it can alleviate joint stiffness and prevent the condition from worsening.
After a treatment plan has been established follow-up visits will need to be scheduled with a rheumatologist. These on-going appointments will keep the rheumatologist updated on the rheumatic condition of a patient and the treatment plan can be adjusted as needed. These follow-up visits could address issues such as reoccurring complications, medications, and coping mechanisms. Rheumatologists can also provide techniques to patients that will help them in regaining function and preventing disability. These follow-up visits with rheumatologist are most often focused on improving the quality of life for patients suffering from a rheumatic disease.
When do I need to set up an appointment with a rheumatologist?
Almost everyone will suffer from some sort of joint or muscle pain, but when is it time to go see a rheumatologist? It is typically advised that if joint pain or muscle pain last longer than expected it may be time to see a specialist. When joint and muscle pain does not resolve itself, there may be additional evaluations that are needed. The first step to getting in to see a rheumatologist begins with the primary care physician. A primary care physician will perform the first evaluation to see if there should be a concern for a more serious rheumatic disease causing the pain. If the primary care physician decides that there may be an underlying rheumatic condition they will be able to refer the patient to see a rheumatologist for an evaluation.
There are a couple situations in which patients should not hesitate to see a primary care physician and get set up with a rheumatologist. If there is a family history of autoimmune or rheumatic disease that runs in the family a referral should be as soon as possible to prevent symptoms from worsening since these diseases run in families. Another situation in which patients should quickly seek a referral to a rheumatologist is in significant pain, especially significant pain that begins to worsen over a very short period of time.
It is important to note that some of the symptoms associated with rheumatic diseases can temporarily resolve. Some signs and symptoms can improve after the initial treatment, but once the medication has been stopped the symptoms can almost instantly return. If patients experience recurring pain when the medication is stopped it is crucial to get back in with a rheumatologist to adjust the treatment plan as needed for a higher quality of life for patients.
Another important note to make is that some medications may actually hinder a proper diagnosis. Some over the counter drugs can actually improve signs and symptoms associated with rheumatic diseases. This can make it even more difficult for a rheumatologist to provide a proper diagnosis especially in a field in which the diseases are already complex and difficult to properly diagnose. If any of the symptoms associated with bone, joint, or muscle pain is left undiagnosed and remain untreated it could cause long-term damage. Damage to joints and muscle by rheumatic disease is something that should not be ignored because these diseases could cause joint damage. This type of damage may not be easily reversed or not reversed at all leading to permanent damage to joints and muscle. This is why it is crucial for patients to seek out a rheumatologist if there is suspicion of an underlying issue causing pain in joints, bones, or muscles. This is even more important in patients that have a known history of rheumatic disease such as arthritis that runs in their family. The sooner a rheumatologist can determine a diagnosis and begin a treatment plan the better results patients will have when following that treatment plan.
Rheumatologist training and education
The first step for someone to become a rheumatologist is typically obtaining an undergraduate degree or advanced degree at a college or university. This usually consists of around three to four years of classes and most premedical undergrad studies are focused on classes such as biology, inorganic and organic chemistry, mathematics, philosophy, physics, and social sciences. Once an undergraduate degree has been completed the next step is to get accepted into a medical school.
Following acceptance to a medical school, a period of an additional four years of classes must be completed in order to become a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.). These four years of medical school are broken down into two different parts each consisting of two years. The first two years of medical school students are required to complete classroom educational courses. These courses involve classes in biochemistry, pharmacology, anatomy, physiology, medical ethics, pathology, microbiology, psychology, and a few classes in laws that govern the practice of medicine. During these first two years of education, students are also taught how to diagnose illnesses, examine patients, and how to properly obtain a medical history of patients.
After students complete the first two years of required classroom education they are then required to complete two additional years in the field. The last two years of medical school consists of students caring for actual patients in clinics and hospitals with direct supervision of an experienced medical doctor. Students are trained through a range of specialty healthcare such as family medical practices, internal medicine, surgery, psychiatry, pediatrics, and obstetrics. During this training phase across a variety of practices students will be taught about rehabilitative, acute, chronic, and preventive care of patients while remaining under the direct supervision of an experienced doctor.
Upon successful completion of medical school, a doctor can then begin their residency. A residency is typically a period of three additional years of education that consists of specialized training and study. This is when a rheumatologist can choose to complete one of the two residencies of either pediatric or internal medicine. Following successful completion of either of these residencies, the doctor is now either an internal medicine doctor or pediatrician. After which additional training of another two or three years is required. These last years of additional training are often focused primarily on rheumatology and once completed a physician can become a rheumatologist.
Rheumatologists usually go on to become board certified to become a practicing rheumatologist. The American Board of Internal Medicine offers a specialized board certification for rheumatology and provides board certification for approved rheumatologists. If a rheumatologist chose to go into the pediatric field of rheumatology there are required to complete an additional two or three years of special training before they can become board certified. Once a rheumatologist has been board certified in pediatric rheumatology they can begin practicing medicine and providing care for children and arthritis or other rheumatic diseases.