Meet the Rheumatologist: Rheumatoid Arthritis
When people ask me what a rheumatologist does, I explain that we’re the medical doctors who deal with diseases that affect the joints, including autoimmune disorders. With an autoimmune disorder, the immune system attacks the body’s own tissues like it attacks an infection. We don’t yet understand why this happens, but it can cause a lot of inflammation. In the case of rheumatoid arthritis (RA), this leads to pain, swelling and irreversible damage to the joints if it goes untreated.
A big part of being a rheumatologist is helping patients manage musculoskeletal pain, and while there isn’t always a pill to make everything get better, I can strategize with patients to figure out what they can do to maintain the important parts of their life despite their chronic condition.
I knew I wanted to do medical research that impacts patient care, and I decided it would be helpful to my research if I went to medical school. I entered a program that allowed me to get an MD as well as a Ph.D., and in the first couple years of medical school, I fell in love with immunology. Immunology is the study of how the immune system affects the rest of the body, and I eventually got my Ph.D. in the field. However, when it came to being a practicing doctor, I wasn’t sure what my focus should be. Fortunately, a professor in my medical school exposed me to rheumatology early on. She taught a class about musculoskeletal physical exam and brought in her own patients to talk to us about their conditions. The experience had a big impact on me. I still remember those patients and their stories. I knew I wanted to develop relationships with the people I treated, and rheumatologists, because they treat chronic conditions, really get to know their patients and their patients get to know them. Plus, rheumatology and immunology are strongly linked, so it felt like the right match for me.
The most rewarding part of my job is, of course, helping patients get better. It’s also extremely rewarding to see my patients take an active role in their own care. I don’t want to be the kind of doctor who’s sitting up on high, making pronouncements about treatment. I love when my patients feel empowered to work with me to find the right care. A big part of that is building a trusting relationship; people have to trust that I’m guiding them in the right direction, and I have to trust that they’re taking ownership of their health. My job is to educate them and make sure they understand how RA affects them, and they need to trust that I’m listening to them and making decisions that will work with their life.
Our goal with treatment is to get the disease well controlled and, hopefully, in remission, which means that the inflammation and symptoms are completely gone. We want to relieve the pain and swelling that come along with RA, and we want to stop the irreversible damage RA can cause to joints.
We are fortunate to have many treatment options for RA. About 30% of patients can get by with just one medication, but often we need multiple drugs to get symptoms under control and protect joints from long-term damage. Currently all of the prescription medications approved to treat RA are designed to suppress some part of the immune system so it stops attacking the joints. We often start with the medication methotrexate. It belongs to a class of medications called disease-modifying antirheumatic drugs (DMARDs) and is considered the cornerstone of most arthritis therapies. If methotrexate isn’t enough, we can replace it or add other DMARD pills to block RA from progressing. In some cases, we might try biologic medications, which are an injectable type of DMARD that prevent inflammation by targeting specific immune cells or the molecules immune cells use to communicate to each other.
It’s frustrating for my patients and me that there’s no crystal ball to tell us which medications will work best. It’s a trial-and-error process to find the right one. Generally, we’ll start with methotrexate and then wait a few months to see how well it works. If the patient comes back and still has symptoms, we then make changes to his or her medications. Most of my patients get better relatively quickly, but I’ll also have cases where it takes a couple of years to figure out the best combination of medications. One major goal of RA research right now is to personalize medicine; we need to find tests that will tell us which drug will work best for an individual patient.
I feel privileged to be a practicing rheumatologist as well as a researcher. I get to treat patients and also spend time performing research that may one day benefit them. It’s rewarding to help patients control symptoms and protect their joints from what used to be a disabling, crippling disease. Today, most of my patients live normal, functional lives. The last few decades have seen huge breakthroughs in RA treatment and we’ve witnessed an explosion of new medications in the last 10 years. The research that comes out of the next 10 to 20 years will increase our understanding of this disease even more, letting us treat RA even more effectively and, maybe one day, curing the disease altogether.