The Daily Schedule Of A Rheumatologist

A rheumatologist is a medical specialist who focuses on the diagnosis and management of rheumatic diseases that affect the joints, connective tissue, blood vessels and soft tissue. Rheumatic diseases and conditions are mostly linked to autoimmune dysfunction that affect the mentioned areas of the body and cause problems such as arthritis and vasculitis.

Training

In order for a doctor to specialise as a rheumatologist they must complete their undergraduate medical degree, that takes 5-6 years to accomplish, in order to become a medical doctor in the first place. The doctor then has to complete 1-2 years of internship training where they work at different surgical and medical disciplines to gain clinical exposure. The doctor is then qualified to specialise further and has to complete a 4 year residency programme in internal medicine and, thereafter, takes part in a fellowship training programme in rheumatology that takes 2-3 to complete.

Rheumatologists are also involved in research studies that are looking into newer medications, called biologicals, that are showing to be very effective in the management of rheumatic conditions.

Diseases managed by Rheumatologists

The conditions and diseases that are diagnosed and managed by rheumatologists include:

Inflammatory arthropathies

• Rheumatoid arthritis.
• Spondyloarthropathies such as reactive arthritis, psoriatic arthropathy, ankylosing spondylitis and enteropathic arthropathy.
• Crystal arthropathies sucha as gout and pseudogout.
• Juvenile Idiopathic Arthritis (JIA).
• Septic arthritis.

Degenerative arthropathies

• Osteoarthritis.

Connective tissue diseases and systemic conditions

• Lupus
• Polymyositis
• Sjögren's syndrome
• Dermatomyositis
• Scleroderma
• Mixed connective tissue disease
• Polymyalgia rheumatica
• Adult-onset Still's disease
• Relapsing polychondritis
• Fibromyalgia
• Sarcoidosis

Vasculitic conditions

• Microscopic polyangiitis.
• Granulomatosis with polyangiitis (previously called Wegener's granulomatosis).
• Eosinophilic granulomatosis with polyangiitis (previously called Churg–Strauss Syndrome).
• Henoch–Schönlein purpura.
• Polyarteritis nodosa.
• Giant cell arteritis (temporal arteritis).
• Serum sickness.
• Behçet's syndrome.
• Takayasu's arteritis.
• Buerger's disease (thromboangiitis obliterans)
• Kawasaki's disease (mucocutaneous lymph node syndrome)
• Hereditary periodic fever syndromes

Soft tissue rheumatism

The following are local lesions and diseases that affect the joints and the structures around the joints including the ligaments, tendons, ligaments capsules, muscles, bursae, nerves, ganglia and vascular anatomy. 

• Lower back pain due to issues like sacro-iliitis.
• Olecranon bursitis.
• Golfer's elbow.
• Tennis elbow.

READ Tendonitis Elbow Treatment - Golfer's Elbow and Tennis Elbow

Diagnostic procedures performed by Rheumatologists

A comprehensive history is taken by the rheumatologist that includes a family history, information regarding the patients previous and current occupations, surgical and medical history and information regarding acute and chronic medication use. The rheumatologist will then conduct a physical examination that includes performing tests that are complex and can only be performed by these specialists. These will be discussed as follows:

Physical examination

• Multiple joint inspection is done on the patient.
• Schober's test examines the flexion of the lower back.
• Musculoskeletal examination:
  1. Screening Musculoskeletal Exam (SMSE) - this is a rapid assessment of the function and structure of the joints and muscles.
  2. General Musculoskeletal Exam (GMSE) - the rheumatologist performs a comprehensive assessment of joint inflammation here.
  3. Regional Musculoskeletal Exam (RMSE) - this is a focused assessments of inflammation, function and structure of the joints and muscles combined with specialized investigations.

Specialized investigations

• Blood tests such as a full blood count (FBC), erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), serum uric acid (UA), anti-nuclear antibody (ANA) and anti-citrullinated protein antibody (anti-CCP) can be requested.
• Imaging techniques such as radiographs (X-rays), ultrasounds, CT scans and MRIs are used to investigate affected joints.
• Fluids aspirated from affected joints are sent to chemical pathology and cytopathology for further analysis.

The Daily Schedule Of A Rheumatologist

A rheumatologist can have patients admitted to a hospital ward and will consult with them on a daily basis until they are well enough to be discharged home or to a rehabilitation hospital for further management. These specialists will also consult with patients of other physicians and surgeons who have requested an opinion from them.

Rheumatologists are expected to provide on call services after hours and on weekends so that primary healthcare workers, casualty doctors and other specialists can get hold of them to discuss a patient's condition. Emergency cases that a rheumatologist would need to see urgently include acute lower backache due to a rheumatic cause, severe acute arthritis, severe acute gout, acute exacerbation in a patient with chronic arthritis, lupus flare-up, rheumatoid flare-up, scleroderma renal crisis, systemic necrotizing vasculitis, erythema nodosum and catastrophic antiphospholipid syndrome.

Monday

A rheumatologist will first deal with the non-clinical issues of the practice before consulting with patients. These administrative tasks include confirming and attending meeting for the week with hospital staff and management as well as medical representatives. Clinical aspects such as the admission lists for patients also need to be confirmed for the week.

Once these issues have been dealt with, the rheumatologist can then begin consulting with patients. Most of the time these patients will be managed conservatively with medication or sent for specialized investigations which are then followed up and discussed with the patient.

Patients can also be admitted for further investigations that need to be done in the hospital and they are managed further depending on the findings of these tests. These patients will include those who have severe pain and inflammation that can only be adequately controlled with intravenous medications.

Tuesday and Wednesday

Rheumatologists will continue to consult with and manage patients accordingly on these days. The specialist will also use this day to fill in motivation letters to the medical insurance companies, fill in chronic prescriptions for patients or do further research for their own academic purposes.

READ Polymyalgia Rheumatica: When Devastating Stiffness Takes Over Your Life

Thursday 

The rheumatologist will continue to see and manage patients during the morning of this day. The afternoon will be used for training undergraduate medical students and post-graduate clinical assistants if the specialist is involved with the academic programme of the local medical school.

It is very likely that a rheumatologist will spend the majority of their week consulting with patients since there is quite a shortage of these specialists in general. Also, they have a lot of patients referred to them by not only primary healthcare workers, such as nurse and general practitioners, but from other specialists too.

Friday

The rheumatologist will consult and manage patients in the morning and deal with any other unfinished administrative issues in the afternoon. The work week can then end once all these aspects have been dealt with.