What to Expect at Your First Rheumatologist Appointment

Whatever the reason, that first appointment is a journey into the unknown. But learning what an initial visit typically entails can help you feel confident and ensure you make the most of your time.

Unfortunately, there's a nationwide shortage of rheumatologists in the United States, and it can take months to get a first appointment, which often means a long time of waiting with unexplained, painful symptoms, says Rachel Wolfe, MD, assistant professor of rheumatology and immunology at Wake Forest School of Medicine and rheumatologist at Atrium Health Wake Forest Baptist, both in Winston-Salem, North Carolina.

The good news is that an initial visit will be quite comprehensive, says Dr. Wolfe. “It's the first step toward making a diagnosis and implementing the appropriate treatment plan,” she says.

Patients should always expect their healthcare providers to pay close attention to them, but this is especially true in rheumatology, says Wolfe.

“In general, you can expect your first rheumatology appointment to last 40 minutes to an hour, and that's because we are going to ask lots and lots of questions. It will hopefully be one of those times that you walk out and feel like the doctor really listened to you,” she says. However, appointments may be shorter than 40 minutes, depending on the complexity of the case.

Here are the various steps you can expect:

Medical History

Come to your first visit prepared to discuss your symptoms in detail, says Jonathan Greer, MD, rheumatologist at Arthritis and Rheumatology Associates of Palm Beach in Florida. Even though they may have your medical records, it's still helpful for them if you point out what you think may be important.

“Rheumatologists rely heavily on your story. To quote my mentor, ‘Patient history is the rheumatologist's scalpel,’” says Dr. Greer.

Greer often asks new patients the following questions:

• When did the symptoms start, and how have they changed?
• Where's the pain located?
• Is there swelling?
• Is your skin affected?
• What makes your symptoms better or worse?
• How do you feel in the morning, and how long does it take for you to start feeling better?
• Do you have a family history of arthritis?
• Have you tried any medications? If so, which ones?

Physical Examination

A physical exam is part of every first visit. Whether you keep your clothes on or change into a gown depends on your symptoms and the doctor, says Wolfe.

“Many rheumatologists will have every new patient get in a gown, because even if you think the problem is in your joints, it doesn't mean that it's not in other places. For example, we may find a rash, and so we want to check things out all over,” she says.

Sometimes it's very clear what the issues are, and there's no need to change into a gown, says Wolfe. If you think that's the case, just make sure you're dressed appropriately.

“If you're coming in for your knees, this isn't the time to wear skinny jeans. In general, it's a good idea to wear stretchy clothes that aren't too tight,” she says.

The physical exam usually includes the following:

• Examining your joints.
• Observing your movements, such as how you walk, bend, and grasp objects.
• Looking for a rash or nodules (bumps) on your skin.
• Listening to your chest for signs of inflammation in the lungs.

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Testing

In some cases, a rheumatologist is able to make a diagnosis based on just your medical history and a physical exam, but often lab tests or imaging are necessary.

Diagnostic tests may include the following:

Blood Tests Blood tests can confirm a rheumatoid arthritis diagnosis in a few ways; for instance, by revealing the presence of certain antibodies such as rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP). But it's important to note that some people with rheumatoid arthritis will have normal blood test results.

Blood tests can also reveal inflammation via erythrocyte sedimentation rate (often called the sed rate) and levels of C-reactive protein. This is another common test for inflammation that can help diagnose rheumatoid arthritis and monitor disease activity and response to treatments.

Imaging Tests Magnetic resonance imaging (MRI) and ultrasound may help diagnose rheumatoid arthritis and evaluate the amount of damage in the joints and the severity of the disease.

Diagnosis

A rheumatologist considers your medical history, physical exam, and test results to make a diagnosis.

“If a person has clear symptoms — for example, a telltale rash — we may be able to make a probable diagnosis on the first visit, but that usually isn't the case. For most rheumatological diseases, diagnosis is a process that can take weeks or months,” Greer says.

Wolfe agrees. “In many cases, at the end of the first visit, we may need more time to observe how they do on certain treatments or perform further testing. It is very possible that you see a rheumatologist, without a clear diagnosis, or you leave with a diagnosis, but not the one you were expecting,” she says.

Treatment Discussion and Plan

Your first appointment with a rheumatologist will typically conclude with a discussion about additional testing or treatment.

“We may not have a diagnosis after the first visit, but we'll discuss the next steps in how we can help you get to feeling better,” says Wolfe.

Possible strategies may include:

• Pain relievers
• Steroids to ease inflammation
• Disease-modifying drugs (DMARDs) or biologic drugs
• Physical therapy or surgery to address inflammation or to replace joints (in some cases)

If your primary care physician refers you to a rheumatologist, ask why.

“Patients often assume that we have their records or information about why they've been referred, but that's not always the case,” says Wolfe. “Ask your doctor why they are sending you to a rheumatologist — that can help set you up for a successful appointment,” she says.

Being an active participant in your care, which includes doing some prep before the visit, can also help you get the most out of your initial appointment with a rheumatologist, says Greer.

Here are a few recommendations for how to get ready for the visit:

• Keep a symptom log. It can take weeks or months to get your first appointment. In the meantime, jot down detailed accounts of your symptoms and where and what time of day they happen.
• Compile a list of current medications and supplements. If there are medications that you took in the past that weren't effective or caused bothersome side effects, put that on the list as well.
• Pull together a detailed medical history. Make sure you have your records or have your primary care doctor send your records over a few weeks before your rheumatologist appointment. If you've had any recent X-rays or MRIs, bring the reports — it could speed the process and help you avoid repeating tests unnecessarily.
• Write up a list of questions. This can help the rheumatologist understand what's important to you and what your goals are.
• Bring a trusted family member or friend. Having an extra set of ears can help you later when you're trying to remember everything the rheumatologist said. That person can also remind you of questions you forget to ask.

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• Your first rheumatologist visit will involve lots of questions and will typically last between 40 minutes and an hour.
• Be prepared to discuss your medical history in detail, including symptoms, medications, and any past imaging or lab results.
• A physical exam will be part of the visit, and you may need to wear a gown depending on your symptoms.
• You may not receive a definitive diagnosis immediately because rheumatological conditions often require further observation or tests, but the rheumatologist will guide you through the next steps.