Expert Interview: When You Can't Get In to See a Rheumatologist

It's an unfortunate trend in the U.S.: Rheumatologists are becoming harder to find. A survey in 2013 by the American College of Rheumatology found that many population centers smaller than 50,000 people had few or no practicing rheumatologists. In some cases, the closest rheumatologist was more than 200 miles away.1

Rheumatologist
As the populations ages, rheumatologists are more and more in demand.

As a result, people with arthritis may have their condition managed by their primary care doctor or another general practitioner, such as an internist or nurse practitioner.

Erich Widemark, PhD, RN, FNP-BC, is a certified nurse practitioner who spent 5 years treating arthritis patients in primary care and outpatient pain management. We spoke to him about what people with arthritis should know when it comes to seeing a rheumatologist versus another practitioner.


Can primary care doctors or other practitioners diagnose different types of arthritis?

Any primary practitioner should be able to diagnose rheumatoid arthritis (RA). Currently there are lab panels available that can quickly determine the most obvious cases of RA and other conditions like lupus. Some complex immune disorders, such as ankylosing spondylitis, can be more of a challenge for a non-specialist to diagnose.

Osteoarthritis is mainly diagnosed by symptoms and imaging tests, and is also able to be diagnosed by primary practitioners.

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Are there types of arthritis that should be treated by a rheumatologist rather than another practitioner?

Rheumatoid arthritis should always be initially managed by a rheumatologist. The primary goal in treating RA is the elimination of joint damage being caused by a patient’s overactive immune system. There are powerful medications available to treat it, but these medications are often given intravenously. Plus, they have significant potential for adverse reactions and side effects, which need to be closely monitored by someone who is familiar with these medications.

Osteoarthritis, on the other hand, is usually the result of joint wear and tear. This is a condition that can be treated mainly by a primary care provider. In some cases—when the pain becomes unmanageable or when a joint needs to be replaced—a referral to an orthopedic or pain management specialist may be appropriate.

Who is most affected by difficulties in seeing a rheumatologist?

I believe this issue goes beyond rheumatology. Specifically, patients in rural or semi-urban areas have traditionally struggled with limited access to specialists.

But while it may be more difficult for a patient in a rural area to see a rheumatologist, modern technology allows local health care providers to have up-to-date access to current practice guidelines. Many national organizations like the American College of Rheumatology publish national guidelines that assist primary providers in doing quite a bit of the initial workup and assist in the care of complicated conditions like RA.

In addition, new telemedicine programs now allow more specialists to be involved in patient care at a distance.

What should patients do if they feel their treatment isn't working or they've been misdiagnosed?

I always recommend several things for patients who are not satisfied with their diagnosis. A second opinion can be helpful, as can a frank and honest conversation with your provider to help you better understand what the diagnosis is based on. Often, it just takes an explanation about the different diagnostic tests involved (SED rate, anti-CCP, rheumatoid factor, etc.) to reassure a patient.

Another solution is for patients to do research online to understand their condition. It is important that this online research come from a reputable and peer-reviewed site to ensure you are getting the most accurate information.

Many professional organizations have posted patient education materials online, available to anyone. That information, along with a visit with someone knowledgeable in general medicine, can be enough to verify a difficult diagnosis.

Doctor and Patient
If you are seeing a general practitioner to treat your arthritis,
be open about all your symptoms, medications, and concerns.

Can primary care providers or other practitioners prescribe the same medications as rheumatologists?

While primary care providers and other practitioners can legally prescribe some of the same medications as rheumatologist, many are uncomfortable doing so because they are beyond what we call their "personal scope of practice." The side effects and adverse reactions of RA medications can be daunting to a provider who doesn't have a lot of experience prescribing them, so at this time rheumatologist are the main professionals prescribing these medications.

Are there any tips that patients should keep in mind if they are seeing a general practitioner to treat their arthritis?

  1. Tell your provider if your joint pain is evolving to include other joints or getting worse in any joint. It's also important for your provider to know about other joint symptoms, such as inflammation or decreased range of motion.
  2. Tell your health care practitioner about any history of past injuries or trauma to affected joints or bones. It's common to develop arthritis at an old injury site.
  3. Notify your primary care provider if you have significant changes in your level of continuous or unmanageable pain to a specific bone or joint. In rare cases, you may need additional tests to rule out other uncommon illnesses such as bone cancer.
  4. Because all types of arthritis can fluctuate and be worse or better depending on many factors, ask your doctor about management tips for factors like weather, stress, or sleep quality.
  5. It's important to stay active with regular stretching and low impact exercises. Ask your doctor about the best options for you to stay active without aggravating joint pain. Usually, swimming or yoga can be great options for someone with joint problems.
  6. Medications to treat arthritis can cause patients to be more susceptible to infection. Tell the medical provider about the medications you are on and if you have had any issues with lingering illness.
  7. One common type of medication used to treat arthritis pain is non-steroidal anti-inflammatory drugs (NSAIDs). Because these can irritate the stomach, be sure to alert your provider to any stomach issues and the amount of these medications that you are taking.

Visit Dr. Widemark's Arthritis-health author page to learn more about his background and experience.

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References:

  1. American College of Rheumatology Committee on Rheumatology Training and Workforce Issues (2013), Regional Distribution of Adult Rheumatologists. Arthritis & Rheumatism, 65: 3017–3025. doi: 10.1002/art.38167
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