- Center for Arthritis & Autoimmunity
- Why Is It So Hard to Find a Rheumatologist?
- Solving the Rheumatologist Puzzle, Serving People With Rheumatic Disease
- How to Find Appropriate Care for Arthritis and Other Rheumatic Diseases
- 8 Tips for Choosing a Rheumatologist
- 9 Signs You’re Seeing the Right Rheumatologist (and 5 Signs You Might Need a New One)
- Signs You Need to See a Different Rheumatologist
- Keep Reading
- Seek a Rheumatologist
- How a Rheumatologist is Going to Help
- How to Find a Rheumatologist
- Survey Finds Patients with Rheumatoid Arthritis and Their Doctors Not Always on the Same Page
- Most doctors believe more patient involvement in decision-making would improve RA management
Center for Arthritis & Autoimmunity
The NYU Langone Center for Arthritis and Autoimmunity can help you manage rheumatologic conditions including antiphospholipid syndrome, autoimmune disease during pregnancy, Behcet’s syndrome, fibromyalgia, gout, metabolic bone disease, mixed connective tissue disorders, osteoarthritis, osteoporosis, psoriatic arthritis, rheumatoid arthritis, scleroderma and Raynaud’s disease, spondyloarthropathy and seronegative arthritis, Sjogren’s syndrome, and systemic lupus erythematosus.
U.S. News & World Report’s “Best Hospitals” ranks NYU Langone among the top 10 hospitals in the country for rheumatology.
When you come to us for care, you have access to a vast array of services, including rheumatologic evaluations, orthopedic and neurological consultation services, participation in clinical trials using advanced interventional therapies, sophisticated diagnostic testing such as musculoskeletal ultrasound, and rehabilitation.
We also provide techniques including arthrocentesis—a simple procedure using a needle to drain fluid from the joints—and injections of intra-articular steroid and hyaluronic acid to reduce inflammation and pain.
As part of NYU Langone Orthopedic Center, patients at the Center for Arthritis and Autoimmunity are under the care of expert rheumatologists who are nationally recognized for their clinical knowledge and their talents as research scientists.
Why Is It So Hard to Find a Rheumatologist?
- Most medical students graduate with a huge amount of debt. But income for subspecialties such as rheumatology — in which there aren’t a lot of tests and procedures — is very low compared with procedure-heavy specialties, such as dermatology and gastroenterology.
- There’s a lack of funding to teaching hospitals for training rheumatology fellows. It costs around $160,000 per fellow for a two-year program. Medicare pays hospitals an extra amount that’s supposed to go to training programs, but the reality is that it only goes to train medical and some surgical residents; none of it goes to train subspecialties. Medical centers have to find their own funds.
Solving the Rheumatologist Puzzle, Serving People With Rheumatic Disease
If you have a rheumatic disease such as RA, don’t panic. The ACR is looking at the following solutions:
- More fellowship funding While there has been an increase in the number of rheumatology fellowship programs and an increase in the number of fellows being trained in these programs, experts predict that even doubling of the number of fellows will not meet the projected shortfall in 2030. (1) “We are hoping that Congress will create a more sustainable way to fund trainees, not necessarily through Medicare. It could be via private insurance or another mechanism,” says Bass. ACR is also encouraging more funding through its own Rheumatology Research Foundation.
- The Pediatric Subspecialty Loan Repayment Program The ACR is lobbying for the program’s support, which would apply to individuals who choose to go into specialties where there’s particular need.
- Targeted doctor training The group hopes to encourage additional rheumatology training for internists in underserved areas.
- More mentoring opportunities “I had great mentors who opened doors for me that I never even knew existed, but students aren’t getting that exposure anymore for a variety of reasons,” says Jonathan Krant, MD, the medical director of the CreakyJoints online patient community and the chief of the rheumatology clinic at Adirondack Health’s Saranac Lake Health Center in Saranac Lake, New York. ACR offers professionals information on preceptorships and a pediatric rheumatology mentoring group.
- Telehealth Seeks to extend coverage to isolated and underserved populations (1)
- More collaboration with primary care physicians (2)
How to Find Appropriate Care for Arthritis and Other Rheumatic Diseases
If you need help finding a rheumatologist, take these steps:
- Go to the ACR website and check out the physician locator.
- Use word of mouth and online investigation. CreakyJoints lists online and local support groups.
- Look for the director of the training program at the nearest teaching hospital. They can make recommendations.
- Nurse practitioners and physician assistants are being trained in rheumatology care. “It’s a small percentage of the workforce, but it is a way to go if that’s an option,” says John FitzGerald, MD, PhD, the interim chief of the division of rheumatology at the David Geffen School of Medicine at UCLA in Los Angeles. Ask around to find one in your area or check out the American Association of Nurse Practitioners website, NPFinder.com.
- Some states have set up telemedicine programs, where you have a video conference with a team. For example, the University of New Mexico School of Medicine has established Project ECHO (Extension for Community Healthcare Outcomes), an educational platform that allows experts to connect remotely with doctors in rural and underserved communities. “It’s a good example of physicians having to get creative to cover a lot of geography,” says Dr. FitzGerald.
- Although they can’t take the place of a rheumatologist, the ACR offers 80 free fact sheets and videos for people living with rheumatic diseases.
8 Tips for Choosing a Rheumatologist
Choosing a rheumatologist is one of the most important and personal decisions you can make for the health of your joints, tendons, ligaments, bones and muscles. You will rely on your rheumatologist’s knowledge and expertise in diseases that tend to be complex, change with time, and can be difficult to diagnose. Take the following issues into consideration when choosing the best rheumatologist for you.
A Personal Decision https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1494×999%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fb9%2Fff%2F84d6b58b4c5192c0ce72c97a2eac%2Fresizes%2F1500%2Fgettyimages-171308317-rf-hg.jpg
A good doctor-patient relationship develops with time and is built on trust and communication. You can ensure a good start by taking the time to find the best rheumatologist who is right for you or a family member. Start with a referral list from your primary care doctor. This list will likely contain rheumatologists who can work closely with your primary care doctor to coordinate your care. Also, ask family, friends, and other healthcare providers for recommendations.
1. Get Referrals https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1490×997%2B9%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Faf%2Fbd%2F32cc02c941c7b4770f88074ac5b1%2Fresizes%2F1500%2Fgettyimages-176825215-rf-hg.jpg
Rheumatologists are dual-board certified in internal medicine and rheumatology. Board certification is one of the most important factors to consider; it tells you that the doctor has the needed training, skills and experience to provide healthcare in rheumatology. Also, confirm that the rheumatologist has no history of malpractice claims or disciplinary actions. You can find the rheumatologist’s medical school, training hospital, certifications, and malpractice and disciplinary history on Healthgrades.com and state websites.
2. Research the Rheumatologist’s Credentials https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F31%2F55%2F19651a35428e9c432cb4393163da%2F11-ways-aca-affects-you-s9-stk-41427385.jpg
When you’re facing complex, changing and, sometimes, vague rheumatic conditions, experience matters. The more experience a rheumatologist has with a condition or procedure, the better your treatment results are likely to be. Ask how many patients with your specific condition the rheumatologist has treated. If you know you need a specific procedure, ask the rheumatologist how many of the procedures he or she has performed and find out about complication rates—complications the doctor has encountered as well as your own risk of complications.
3. Consider the Rheumatologist’s Experience https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1496×1001%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F94%2Fb7%2F69f52bb846499063499d36551edc%2Fresizes%2F1500%2Fgettyimages-699087109.jpg
It is important for you to feel comfortable with your rheumatologist’s gender because you will need to openly discuss personal information. Consider whether gender makes a difference to you and whether you might feel inhibited or awkward in front of a rheumatologist of a certain gender. Be sure to ask the rheumatologist about his or her recent training and experience specifically related to your condition and your gender, and if he or she cares for women and men differently.
4. Consider Gender https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1494×999%2B5%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F33%2F3c%2F9bc06b4f4a7cac1e8649a80b4a1b%2Fresizes%2F1500%2Fgettyimages-187973885-rf-hg.jpg
Your doctor’s hospital is your hospital. For this reason, it’s important to consider the quality of care at the hospital where the rheumatologist can treat patients. Hospital quality matters to you because patients at top-rated hospitals have fewer complications and better results. Additionally, consider whether the hospital’s location is important to you. Should you need to go the hospital for tests or treatment, you want the location to encourage, rather than discourage timely care.
5. Research Hospital Quality https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fb2%2F3d%2F055afe234913b43df1c8afbb8f6b%2Fimage-hospital-emergency-entrance-sign.jpg
Choose a rheumatologist with whom you are comfortable talking and who supports your information needs. When you first meet the rheumatologist, ask a question and notice how he or she responds. Does he or she welcome your questions and answer them in ways that you can understand? Afterwards, did you feel rushed or engaged? Find a rheumatologist who shows an interest in getting to know you, who will consider your treatment preferences, and who will respect your decision-making process.
6. Evaluate Communication Style https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1494×999%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F41%2Fd2%2F7a0f533d4624831f8dbc82bb607c%2Fresizes%2F1500%2Fgettyimages-174973389-rf-hg.jpg
Reading what other people have to say about a doctor can provide insight not only into how a doctor practices medicine, but also how his or her medical practice is operated. Patient satisfaction surveys typically ask people about their experience scheduling appointments, wait times, office environment, and office friendliness. You can learn what people have to say about their level of trust with a doctor, how much time he or she spends with their patients, and how well the doctor answers questions.
7. Review Patient Satisfaction Surveys https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F2f%2F4e%2Fc7fd696248f0b4e52d473561299e%2Fimage-customer-satisfaction-survery.jpg
Your insurance coverage is a practical matter. To receive the most insurance benefits and pay the least out-of-pocket for your care, you may need to choose a rheumatologist who participates in your plan. You should still consider credentials, experience, outcomes, and hospital quality as you select a rheumatologist from your plan.
8. Know What Your Insurance Covers https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F55%2F29%2F2a8d29104516adf5c531b36c22af%2Frheumatologist-SS-9.jpg
9 Signs You’re Seeing the Right Rheumatologist (and 5 Signs You Might Need a New One)
2. They’re thorough
Since a lot of patients get shy or forgetful once they step foot in the doctor’s office, Dr. Blazer recommends bringing a list of concerns and questions to go over with your doctor. If she’s cool going over that list, that’s a good sign. She should also have no problem explaining your lab tests and bloodwork in detail. You should leave your rheumatologist appointment feeling like no stone was left unturned.
“My rheumatologist takes his time, explains his thought process, and why he is doing what he is doing,” says Deb Hanzelik. Barbara Mendez appreciates that her doctor “talks ‘to’ me, not ‘at’ me.”
3. They go above and beyond
Don’t you just hate it when you have to call your doctor’s office to get test results? It’s a nice touch when they take the time to reach out to you first. One of my RA pals says her doctor actually calls her on weekends. My doctor called me the day aftermy last appointment to talk about my thyroid test results. I was kind of shocked at his expediency but I greatly appreciated it. Mendez is grateful for that kind of care, too: “My doctor will call when my inflammation markers are elevated,” she says, “to see if I want to come in sooner to see her or just start a prednisone burst pack.”
New technology may mean new norms and ways of communicating for a lot of rheumatologists and their patients. “I have my doctor’s personal cell phone number so if I never need anything, I can call or text her and she always gets back to me right away,” says Layla Tzoras.
And yet Hanzelik’s rheumatologist still takes the time to write her by snail mail. “I received a letter from him four days after my second appointment,” she recalls. “In it, he stated that he was giving my case more thought and added in new tests and sent me ‘scripts to get them done. Can’t ever say I had a doctor think more on my case after I left the office. He has called me after hours on his personal cell phone to review blood results when he could have easily left me a message to call him the following day.”
4. They’re honest and compassionate
When you’re managing a chronic disease, you don’t always get good news. So a doctor’s bedside manner matters. A lot. “He treats me like an adult,” Murray Mu says about his rheumatologist. “He’s perfectly frank and at the same time he shows a lot of empathy.”
Odds are that your doctor will not have arthritis, so they probably will not know what it literally feels like to live with a chronic inflammatory disease, says Dr. Blazer. Though Robin Martinez’s RA doctor has chronic back pain and her nurse practitioner has RA, and she feels like that has a positive impact on her treatment. “He understands the pain component,” she says. “And my nurse has been on many of the RA meds and is now on biologics.”
However, there are many ways your doctors and nurses can show they are able to sympathize with you, and that includes doing everything they can to make sure you have as little pain as possible. If you have a doctor who will stop at nothing to make you feel better, you’ve got the right guy or gal. There should always be another avenue to go down. Failure should not be an option.
5. They communicate with your other doctors
Inflammatory arthritis can cause or be associated with a host of ancillary issues — eye problems to anxiety and depression to other autoimmune diseases. So it’s essential that your rheumatologist be in contact with all of your doctors, especially your primary care physician. “Your primary should be looped in,” Dr. Blazer says, “because they’re responsible for your holistic care. They should be aware of what’s going on. Continuity of care is essential.”
Debra DeWitt’s rheumatologist keeps track of the tests her other doctors order and “she discusses those results with me, too. She lays out options, then helps me decide what to do.” Mendez appreciates that by the time she comes in the room, her doctor has already read and gone through all of her recent doctor appointments and their notes and lab results/tests. It’s not like Evelyn Wood speed reading right in front of her (that’s a joke for Gen-Xers).
6. They will squeeze you in
If you’ve been in the military, you know it can take eons to get an appointment at a veteran’s hospital and there’s not much you can do about it. But for the rest of us, it’s totally unacceptable to wait months for an appointment, especially if you’re in excruciating pain. A good rheumatologist’s office will find time for you.
Vanessa Gonzalez couldn’t get an appointment with her doctor for two months and resorted to popping a lot of ibuprofen, which could be dangerous to her kidneys. “The receptionist told me there were no openings,” she laments. “If I didn’t at least take ibuprofen, I wouldn’t be able to go to work anymore, let alone get up to make myself something to eat. I was so irritated with my doc.”
7. They have a friendly, efficient staff
The receptionist, the nurses, the lab technicians, and everyone in your rheumatologist’s office will feel like family after you’ve seeing them for years. (Hopefully, it’s not a dysfunctional family.) The staff at my doctor’s office helps make my visits as pleasant as possible. I look forward to seeing Magda at the reception desk; she always makes sure I have enough parking validation. Selma draws blood out of my thin-skinned hand like such a pro that it doesn’t even hurt anymore. And Arliz always gets me a pillow for my throbbing feet while I get my three-hour infusion. They run the office like a well-oiled machine.
“I do love that my nurse knows me by name,” Shannon Lockheart agrees. “She draws my blood painlessly every time and she always calls me back with whatever answer I need after consulting with my rheumy.”
8. They are up to date
How do you know if your doctor is aware of the most recent advances in RA treatment? “All doctors are required to keep up with continuing medical education, the latest literature, and the newest drugs,” says Dr. Blazer, though she adds that physicians affiliated with academic medical centers tend to have more rigorous standards for continuing education. “I like that my doctor is up on all things current,” says DeWitt.
When choosing a rheumatologist, you can search online to see if your doctor attends or speaks at conferences or publishes research in medical journals. Also check if their group, practice, or university lists specific requirements for making continuing education a part of their mission as a physician, Dr. Blazer suggests. You can also call the office and ask what is expected of their doctors. (I wouldn’t, but you can! Just being honest.)
9. They get you
According to an article in the Harvard Business Review, sharing a cultural or racial background with your physician can “help promote communication and trust.” Since 58 percent of doctors are white and, according to a UCLA study, only 9 percent of academic medical practices have procedures for connecting patients to LGBTQ-competent physicians, it can be difficult for minorities and gay folks to find doctors they feel the most comfortable with.
Not saying that you should only see doctors who are exactly like you, but it could help. Unfortunately it’s nearly impossible. I can’t even find a stat that says how many LGBTQ doctors there are. But I did find a stat that says 30 percent of sexual minority medical students remain in the closet for fear of discrimination.
However, this brings me back to points one and four. Even if your doctor has a different background from you, being compassionate and a good listener can go a long way.
Signs You Need to See a Different Rheumatologist
1. They minimize your pain
Especially if you’re a woman. Research shows that 70 percent of people with chronic pain are female, and yet there can be a real disparity in how they are treated. Research indicates women’s pain is more likely to be ascribed to emotional rather than physical causes. When men and women present with similar symptoms, women are more likely to be prescribed sedatives over pain medication.
The gender bias is real but you really don’t have to deal with it. If you feel like your rheumatologist (or any doctor) isn’t taking your pain or other symptoms seriously, move on to someone who will. “It’s definitely true that women feel less heard in the doctor’s office,” Dr. Blazer confirms.
2. They treat the symptom, not the patient
You’re not a guinea pig; you’re a human being, so you shouldn’t be treated like a faceless cadaver by your rheumatologist. Stacy Nystrom experienced this at her last appointment. “I’ve been talking Plaquenil for a little over a year, and my dose increased a few months ago, which has helped,” she explains. “But I have a new insurance plan for 2019 and now it’s costing me almost $100 per month. My rheumatologist’s recommendation? ‘If you can’t afford it, stop taking it.’ What? That’s all you can come up with? I was so irritated and anxious.” Thank you, next.
3. They obsess about your weight
“Have you ever considered going on a diet?” That question is not the answer to every problem an arthritis patient has. And yet, many of us find ourselves having that conversation with our doctors more than we’d like. Weight management is a real issue for rheumatoid arthritis patients because we are more likely to develop diabetes and heart disease. “There is an obesity epidemic and it does affect inflammatory arthritis. Every pound you’re overweight puts four pounds of added pressure on your knees,” Dr. Blazer says. “TNF inhibitors like Humira and Enbrel don’t work as well in people who carry excess weight.”
At the same time, she acknowledges that every conversation should not revolve around weight management. “It can be a delicate subject,” she adds. “But it is important to be able to talk about healthy living and nutrition and weight management. That said, it should be ‘a part of.’ It shouldn’t feel like a badgering session.”
4. You see a PA more often than the rheumatologist
It’s been shown that physician assistants are “actually better and more efficient than physicians at following protocol procedures like checking blood sugar or blood pressure,” Dr. Blazer says. “But for complex medical diseases like rheumatoid arthritis, physicians have more training.”
Make sure you understand how your practice uses physicians versus other care providers such as physician’s assistants or nurses. It’s perfectly fine to have different kinds of providers on your health care team, but you should know in what circumstances you will tend to see which experts. When you’re chronically ill, you want to feel like you’re getting the absolute best care possible.
5. The staff seems like a disaster
“It is impossible to get anyone on the phone at my rheumatologist’s office,” says Michelle Montcalm. “Every time I call, it goes straight to voice mail. Often, my calls are not returned or at best, the receptionist calls back two to three days later. Very frustrating!” If you always get the runaround on the phone, experience long waits to see the doctor, and get overall major ’tude, find a new practice. This is your health. You can’t afford to mess around with that!
- 17 Things Your Rheumatologist Wishes You’d Stop Doing Already
- 15 Things Doctors Don’t Always Tell You About Rheumatoid Arthritis (But You Really Should Know)
- News: A Rheumatologist Shortage Is Looming
When dealing with fibromyalgia, it is imperative that you find the right course of treatment and care in order to minimize the effects this illness has on your overall health.
Those who are dealing with fibromyalgia may be in excruciating pain, have stomach issues and feel as though every day is a huge battle to even get off the bed.
However, with the expertise of a medical professional, you can find methods for learning how to live with this pain and having a life.
Seek a Rheumatologist
A rheumatologist is a medical professional who deals specifically with rheumatic issues such as fibromyalgia. This is the medical professional that you must be looking for if you want to get true professionals opinion on how to treat the illness and keep your life as you want it.
A rheumatologist will have completed four years of pre-medical training at a college, then four years of training through a medical school.
Those who are classified as rheumatologists will have completed two to three years of specialized training and education in rheumatic disease and treatment, while also working for three years in internal or pediatric medicine fields. With this amount of training, these professionals are the best option for finding a treatment plan that is going to work for you.
How a Rheumatologist is Going to Help
Just how is a rheumatologist going to help with the fibromyalgia that you suffer from? Due to the nature of the practice, these professionals are going to be able to rule out any other issues that are often confused with fibromyalgia.
They see these symptoms day in and day out, thus they are often able to diagnose this with ease. Some of the items that a rheumatologist will look at upon first seeing a patient:
- The points of muscle pain that the person is experiencing
- Tender points throughout the body
- Any redness or swelling in which the person may be experiencing
- Measuring the stiffness of the patient
- Looking at the range of motion that the patient may be lacking
As a rheumatologist is looking at the patient, he or she may order several types of tests to not only see the extent of damage the body has from fibromyalgia but also to ensure that they are dealing with a clear case of fibromyalgia. These tests may include:
- Ultrasounds of the joints affected
- An MRI of certain areas of the body that are affected
- Electromyography tests
- An analysis of the fluid in the joints
- Tests that determine bone density
Most every rheumatologist is going to take a lot of time when you first visit their office. Expect this first appointment to take quite some time.
The doctor is going to look at your medical history, talk about the issues that you are having now, then start ordering these tests to be completed.
These tests are probably not going to be completed at one visit. They may require going to various other locations to get the tests you need.
However, this is a small price to pay, as the rheumatologist can give you an idea of how to improve your life and how to stop fibromyalgia from running it!
How to Find a Rheumatologist
How does one find a rheumatologist to help with their fibromyalgia? Most people will find that in order to see this type of doctor, they will need to get a referral from their general practice doctor.
Most insurance companies are going to require this in order to pay for this visit. Also, keep in mind that your insurance company may limit which rheumatologist that you can go with. If this is not the case, you will find that you do have several options to find the doctor that is going to meet your needs!
Call your Local College of Rheumatology
One of the first steps when searching for a rheumatologist is to call your local College of Rheumatology. They can provide you with the names and addresses of those rheumatologists in your area. If there is no doctor in your immediate area, they can help with finding one that is near you.
Look at Reviews Online
For those who find a few rheumatologists that they want to consider, they need to do a little research online. Most patients are going to tell the world if they have a great or awful experience with a doctor.
Be sure to check out those fibromyalgia groups that talk about which doctor they visit. This can be great information to help you choose the one doctor that is going to benefit you the most!
These reviews can be a great way to narrow down the list of those doctors whom you may be considering. Also, consider who your general doctor recommends to you!
Call for an Appointment
Many doctors want their patients to feel comfortable, so they offer a onetime meeting to see if they click together. You can call the rheumatologist that you are considering to see if they can offer a quick meet and greet.
This meet and greet should give you a good idea as to whether you are comfortable with the doctor or not. It can also be a chance for the doctor to explain how they have helped other patients with fibromyalgia, which showcases how they could potentially help you.
Make sure to meet with the top three rheumatologists that you are considering. From there, you can make the best decision for dealing with your fibromyalgia. It may require putting in a bit of work before deciding on which doctor to go with.
However, it is going to be well worth it! Fibromyalgia is an illness that affects numerous people, and it can greatly affect just how well you enjoy life.
Do not let this illness rule your life, a rheumatologist is going to the best option for finding relief and learning how to change your life to avoid suffering from this issue.
• The small joints of the hands or feet are affected.
• More than one joint is affected.
• There has been a delay of three months or longer between onset of symptoms and seeking medical advice.
Offer to carry out a blood test for rheumatoid factor in adults with suspected RA who are found to have synovitis on clinical examination. Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor. X-ray the hands and feet in adults with suspected RA and persistent synovitis.
Diagnosis is essentially clinical; investigations are important in assessment and exclusion of other possible diagnoses.
- ESR, CRP and plasma viscosity: usually raised but may be normal.
- FBC: normochromic, normocytic anaemia and reactive thrombocytosis are common in active disease. Raised ferritin but low serum iron concentration and total iron binding capacity.
- LFTs: mild elevation of alkaline phosphatase and gamma GT.
- Antinuclear antibody: positive in SLE and related conditions; also in up to 30% of RA patients and weakly positive in up to 10% of the normal population.
- Uric acid/synovial fluid analysis: excludes polyarticular gout.
- Urinalysis: microscopic haematuria/proteinuria may suggest connective tissue disease.
- Rheumatoid factor in people with suspected RA who are found to have synovitis on clinical examination. Rheumatoid factor: positive in 60-70% of patients (and 5% of the normal population).
- Anti-cyclic citrullinated peptide (anti-CCP) antibodies in an individual with suspected RA, if the patient is negative for rheumatoid factor, and there is a need to decide about starting combination therapy. Anti-CCP has been found to be more specific than rheumatoid factor in RA and may be more sensitive in erosive disease.
- X-ray the hands and feet early in the course of the disease in people with persistent synovitis in these joints. X-rays may show soft tissue swelling, periarticular osteopenia, loss of joint space, erosions and deformity.
See the separate articles on Management of Rheumatoid Arthritis and Disease-modifying Anti-rheumatic Drugs (DMARDs).
NICE has published guidance on the standards of care for people with RA. Early involvement of secondary care is very important for establishing the diagnosis, early use of DMARDs and ensuring full access to all available resources.
- Adverse effects on work and social life are common. Many people with RA have restricted mobility and difficulties with activities of daily living. Inability to work may occur early in the course of the disease, especially in someone with a manual occupation. Approximately one third of people stop work because of the disease, within two years of onset, and the proportion of people who have stopped work increases with time.
- Depression is common.
- Inflammatory conditions other than those involving joint and tendon.
- Vasculitis, vasculitic ulcers.
- Pleurisy, pleural effusions, pulmonary fibrosis.
- Pericarditis, pericardial effusions, myocardial infarction, myocardial dysfunction, myocarditis.
- Dry eye syndrome (keratoconjunctivitis sicca).
- Felty’s syndrome (enlarged spleen and low white cell count); can present with an infection or leg ulcer.
- Amyloidosis (rare).
- Orthopaedic complications: carpal tunnel syndrome, tendon rupture (particularly extensors of fingers or thumb), cervical myelopathy (usually after severe and long-standing RA), osteoporosis, articular deformities and functional impairment.
- Infectious complications: increased risk of infections. Pulmonary infection and generalised sepsis are particular risks. Septic arthritis is a rare but serious complication.
- The prognosis is variable. The clinical course is typically periods of exacerbations and remissions but may be mild self-limited disease or a chronic progressive illness. Approximately 40% of patients become disabled after ten years. The prognosis is worse when diagnosis and treatment are delayed.
- A worse prognosis for joint damage and disability is associated with:
- Age younger than 30 years, male.
- Insidious onset.
- Extra-articular manifestations, a large number of involved joints, systemic symptoms, persistent anaemia of chronic disease.
- HLA-DRB1*04/04 genotype, a high serum titre of autoantibodies (eg, rheumatoid factor, anti-CCP), raised levels of complement C1q.
- Early X-ray evidence of bone erosions.
- RA that remains persistently active for longer than one year.
- There is increased mortality, particularly due to cardiovascular disease, infection, vasculitis, and poor nutrition.
Survey Finds Patients with Rheumatoid Arthritis and Their Doctors Not Always on the Same Page
Most doctors believe more patient involvement in decision-making would improve RA management
New York, NY—November 14, 2016
A large global survey finds gaps in communication between doctors who treat rheumatoid arthritis and their patients, even though most physicians believe good communication and patient engagement are important to achieve the best outcomes.
The research, “Understanding the Importance of a Patient’s Role in the Management of RA: Physician- and Patient-Based Survey” was presented at the American College of Rheumatology/Association of Rheumatology Health Professionals annual meeting on November 13 in Washington, DC.
“Rheumatoid Arthritis (RA) is a chronic, debilitating disease affecting 1.5 million people in the United States,” said Allan Gibofsky, MD, a rheumatologist at Hospital for Special Surgery and senior study author. “The survey was launched to gain a better understanding of the similarities and differences in physician and patient perspectives, with the goal of improving patient care.”
The RA NarRAtive Global Advisory Panel, a group of 39 rheumatology experts from around the world including Dr. Gibofsky, developed the surveys regarding RA treatment and management for both patients and health care providers. They were distributed in 15 countries between September 2014 and January 2016. More than 3900 patients and more than 1600 physicians completed the questionnaires.
Some of the survey findings:
- Among the doctors, 90% of respondents were satisfied with their communications with patients, however, 68% acknowledged, ‘I wish my patients and I talked more about goals and treatment.’
- The majority of physicians believed that setting treatment goals and developing a disease management plan with their patients are essential for the successful management of RA. Yet, results from the patient survey revealed that few patients had shared their treatment goals with their doctor or realized they had a disease management plan in place.
- Only 53% of patients acknowledged that dialogue with their health care provider would optimize the management of their RA.
- 61% of patients felt uncomfortable voicing their concerns or fears to their doctor.
- RA remission was ranked higher in the physician survey than in the patient survey as a treatment goal. Patients were more likely to cite symptom reduction as a treatment goal.
- Overall, 88% of doctors agreed that patients who are involved in making treatment decisions tend to be more satisfied with their treatment experience; 74% felt that patients who are not involved are less likely to adhere to treatment.
- Doctors and patients had similar views on what they would most like to change about currently available RA medications, including the severity of side effects, cost and efficacy.
“Studies show that good communication and the involvement of the patient in decision-making are critical to achieve optimal care,” said Dr. Gibofsky. “The hope is that this survey represents the beginning of a road map to address deficiencies so we can ultimately improve patient care.”
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Study Title: “Understanding the Importance of a Patient’s Role in the Management of RA: Physician- and Patient-Based Survey”
Authors: Ara Dikranian1, James Galloway2, Joern Kekow3, Cristiano A.F Zerbini4, Maria de la Vega5, Gavin Lee6, Anna Maniccia7, Eustratios Bananis8, Dario Ponce de Leon9 and Allan Gibofsky10, 1San Diego Arthritis Medical Clinic, San Diego, CA, 2King’s College, and King´s College Hospital, London, United Kingdom, 3University of Magdeburg, Clinic of Rheumatology, Magdeburg, Germany, 4Centro Paulista de Investigação Clinica, São Paulo, Brazil, 5CEIM Investigaciones Médicas, Buenos Aires, Argentina, 6Hong Kong Sanatorium & Hospital, Hong Kong SAR, China, 7Pfizer Inc, New York, NY, 8Pfizer Inc, Collegeville, PA, 9Pfizer Inc, Lima, Peru, 10Rheumatology, Weill Cornell Medicine, and Hospital for Special Surgery, New York, NY
The study was funded by Pfizer Inc.