RHEUMATOLOGY
A Rheumatologist is a pediatrician or an Internal Medicine (adult medicine) physician with specialized training who cares for patients with diseases that affect the musculoskeletal system, conditions that are inflammatory or autoimmune in nature. Their training includes 4 years of medical school, 3 years of Pediatrics or Internal Medicine and then 2 to 3 more years of specialization in Rheumatology. Unlike Orthopedic physicians, they do not perform surgery on their patients. These Rheumatologic conditions fall into mostly 3 categories: Inflammatory, Connective Tissue (structures involving supporting structures like tendons and ligaments) and Autoimmune Disorders. Some of these diseases may have a genetic component. Rheumatologists treat a wide range of conditions including Lupus, Inflammatory Arthritis (including Gout, Psoriatic Arthritis, Rheumatoid Arthritis, Ankylosing Spondylitis), Systemic Sclerosis (or Scleroderma), Vasculitis (inflammatory condition of blood vessels), Myositis, Osteoporosis, and other Autoimmune disorders. Some clinicians also manage Osteoarthritis and Fibromyalgia which are chronic medical conditions, but Primary Care Physicians can generally manage these medical issues on their own.
Another feature of Rheumatology that differs from Orthopedics is the potential for involvement of other organ systems in Rheumatologic diseases. The Rheumatologist will perform a thorough physical exam to assess for involvement of other organs systems such as the lungs, heart, kidneys, central and peripheral nerves and liver.
When should a Rheumatologist be consulted? One reason would be a strong family history of Autoimmune or Rheumatic Disease. Another reason would be for a constellation of symptoms which may be seen in Rheumatic diseases, for example - dry eyes or mouth (not associated with medications), alopecia, muscle weakness (in absence of known neurologic cause), stiffness upon awakening of more than 30 minutes relieved with activity or heat, swelling and warmth of joints, rash precipitated by sun exposure, rash associated with scarring of scalp, Raynaud’s (pallor or cyanosis of extremity, associated with pain with cold exposure), eye redness with pain and poor tolerance of sunlight.
How can I facilitate a referral to a Rheumatologist? As the Rheumatologist attends to multiple organ systems when assessing a patient, communication with the Primary Care Physician is essential. Requesting the last office note, imaging of the musculoskeletal system, heart and lungs including Echocardiography, tissue biopsies, and lab work can greatly assist the Rheumatologist in clarifying the diagnosis on the initial office visit. A patient ‘s journal of their symptom history including timing, relevant travel, associated infections, adjustments of medications, associated sleep, diet and activity can also be very beneficial.
The evaluation by the Rheumatologist will include a thorough history and physical examination. Testing may be ordered including blood work, echocardiogram, pulmonary function testing, Xray CT or MRI imaging, diagnostic aspiration, NCV or EMG studies. Potential referrals to Specialists may also be generated.
As for treatment options, there are many with various means of action- from traditional anti-inflammatories, to corticosteroids, to immunosuppressives (both traditional such as hydroxychloroquine and Methotrexate) to new generation Biologics such as anti TNF, anti JAK, anti-interleukin therapy, or physical therapy. The Rheumatologist works most effectively with other providers including Orthopedic Surgeons, Physiatrists and Physical Therapists to optimize musculoskeletal health. The greatest and most relevant consideration when referring to a Rheumatologist is to identify the etiology of the patient's symptoms, formulate a personal care plan and potentially offset end organ damage, optimizing to the greatest degree possible the patient’s quality of life.
