Winter 2019 (Volume 29, Number 4)

What is a Rheumatologist?

By Philip A. Baer, MDCM, FRCPC, FACR

“What's in a name? That which we call a rose
By any other name would smell as sweet.”
– Juliet, Act 2 Scene 2 of "Romeo and Juliet" by W. Shakespeare

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In my one physician, one secretary rheumatology office setup, some of the most interesting one-sided conversations are those I overhear between my secretary and prospective patients. After a referral is received and approved, my secretary will call the patient to book a mutually agreeable time for a first consultation. While this should be simple in theory, in practice it seems to be frequently quite challenging.

For one, patients often seem to be astonished that we are calling them. “Didn’t your family doctor tell you they were sending you to see a rheumatologist?” I hear her say. Apparently not. The unheard reply often seems to be, “What is a rheumatologist?” My secretary is ready for that one: “A rheumatologist is a specialist in arthritis.” That usually works well for someone with peripheral joint pain. Of course, we have many referrals regarding abnormal serologic tests, high creatine kinases (CKs), new unilateral headaches and unusual rashes, and these patients often have no joint pain. The stock answer about what a rheumatologist does must mystify them.

While the CRA website is silent on the issue, the American College of Rheumatology (ACR) website answers the question this way: “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.” (www.rheumatology.org/I-Am-A/Patient-Caregiver/Health-Care-Team/What-is-a-Rheumatologist).

Maybe I need to give that scripted answer to my secretary.

The ACR has improved the definition of a rheumatologist over time. I still have a 1987 booklet from the American Rheumatism Association (now the ACR) entitled: “The Rheumatologist: The Doctor who Specializes in Treating Aches and Pains.” Really! We have come a long way, though it was only recently that the ACR’s premier journal was retitled Arthritis and Rheumatology, instead of Arthritis and Rheumatism.

I used to think that rheumatology, being a “back of the book” specialty in my old internal medicine textbooks, was unique in having this type of issue. However, even glamorous cardiology has websites explaining “What is a Cardiologist?” This includes the website of the American College of Cardiology (www.cardiosmart.org/Heart-Basics/What-is-a-Cardiologist), which defines the question this way: “A cardiologist is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels.” They don’t mention super-hero doctor, extremely well-paid doctor, or doctor most likely to save lives on TV.

Our no-show rate is fairly low, so eventually I meet most of these new patients face-to-face. Some confess they don’t know why they were referred. “I saw several specialists and no one could find anything, so they sent me to see you.” “Don’t you do knee replacement surgery?” Apparently they didn’t read the full ACR information piece: “Rheumatologists treat joint disease similar to orthopedists but do not perform surgeries.” Actually, I don’t see much similarity between how rheumatologists and orthopedic surgeons treat joint disease, but that may be a story for another day. Similarly, the ACR states that “Common diseases treated by rheumatologists include osteoarthritis, gout, rheumatoid arthritis, chronic back pain, tendinitis, and lupus.” Overburdened Canadian rheumatologists would probably drop three of those diagnoses from the list.

Meanwhile, I keep listening to my secretary playing defense: “I’m sorry but the office is not open evenings and weekends.” “Yes, the office is closed on Wednesdays, but that doesn’t mean the doctor is not working.” “Yes, the earliest routine appointment really is three months away.” “No, we do not validate parking chits.” I suspect access to care issues will be the subject of a future article in this series.

Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario