Our Approach to Rheumatology Care

Meet Dr. Syed Alam, MD, FACR

Double Board-Certified, Fellowship-Trained Rheumatologist · Musculoskeletal Ultrasound Trained · 10+ Years of Experience

Dr. Alam completed his rheumatology fellowship at Temple University Hospital after an internal medicine residency at John H. Stroger, Jr. Hospital. His clinical interests include rheumatoid arthritis, lupus, psoriatic arthritis, gout, Sjögren’s disease, osteoporosis and other rheumatic conditions.

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Diagnose first, and say so when it is not clear

A great deal of harm in rheumatology comes from treating a label rather than a patient. Once a diagnosis is written down it tends to follow a person through their records for decades, and it is remarkably hard to dislodge even when the evidence for it was thin at the time.

So the first task is to establish what is actually happening, and the second is to be honest about how confident that conclusion is. Some rheumatic diseases announce themselves clearly at a first appointment. Others only declare their nature over months, and no test compresses that timescale.

What we say when we do not yet know

That we do not yet know, along with what is being considered, what would confirm or exclude each possibility, and when we will look again. That is a more useful position than a provisional label offered for the comfort of having one, and it leaves the record clean.

Undifferentiated inflammatory arthritis is a legitimate working description, not a failure. A meaningful proportion of such cases resolve entirely, and others gradually reveal themselves as rheumatoid or psoriatic disease. Both outcomes are managed better without a premature name attached.

Treat to a target

Modern rheumatology is built on a straightforward principle that took the specialty a long time to adopt: set an explicit target, measure against it at intervals, and change treatment when the target is not met. It is the same logic used for blood pressure or diabetes, and it produces substantially better outcomes than adjusting treatment on impression.

The target

For inflammatory arthritis the target is remission, meaning no swollen joints and normal inflammatory markers. Where remission is not achievable, the target is the lowest disease activity that can be sustained without unacceptable side effects. For gout the target is a uric acid level below a defined threshold, which is what actually stops attacks. For osteoporosis it is preventing the next fracture rather than moving a number.

The measurement

Disease activity is scored using validated measures combining the number of swollen and tender joints, an inflammatory marker and the patient's own assessment. These short questionnaires look like paperwork and are not. They are what turns has it improved into a question with an answer, and increasingly they are what an insurer requires before approving the next treatment.

The consequence

If the target is not met within an agreed period, usually around three months, treatment changes. Not being at target after a fair trial at an adequate dose is not a reason to wait longer; it is the trigger for the next step. A great deal of avoidable joint damage happens during periods when everyone knew a treatment was not working and nobody changed it.

Illustrative photograph rather than a picture of this practice or its patients.

Order the tests that change your care

It is tempting to send a broad autoimmune panel at the first appointment on the grounds that more information cannot hurt. It can, and routinely does.

A positive ANA is found in up to 15 percent of healthy adults. Sent without a clinical question, such a panel generates a result that means nothing, which then requires explaining, sometimes repeatedly, and which occasionally leads to years of monitoring for a disease the person was never going to develop. A substantial number of rheumatology referrals exist only because a test was sent that should not have been.

What this means in your appointment

• Tests are ordered at the end of the consultation, once there is a question for them to answer
• Each test requested has a stated purpose, and you should be told what it is
• Further antibody testing follows a positive screening result only where the picture fits
• Imaging is chosen for what it can show: ultrasound for active inflammation, MRI for the spine and sacroiliac joints, plain films for established damage
• A test that will not change what we do next is not ordered

The corollary is that normal results do not close the question. Roughly one in five people with rheumatoid arthritis have negative antibodies, psoriatic arthritis has no confirmatory blood test, and axial spondyloarthritis is diagnosed on imaging and clinical pattern. Clinical judgement outranks a normal panel.

Decisions belong to the patient

Almost every meaningful choice in rheumatology involves a trade-off rather than an obvious right answer. Suppressing an immune system reduces inflammation and raises infection risk. Steroids work quickly and cost bone over time. A biologic may control disease that nothing else has touched, and it requires screening, monitoring and a good deal of administrative effort.

Those trade-offs depend on facts we do not have: what you do for a living, whether you have young children or care for an elderly parent, what you can tolerate, what frightens you, what you are unwilling to give up. A decision made without that information is a guess wearing a lab coat.

What we ask of you

• Say when a plan does not fit your life. That is clinical information, not an inconvenience
• Say when you have stopped a medicine. We can work with it; we cannot work around not knowing
• Ask why. If a reason cannot be explained clearly, that is a problem with the reasoning
• Tell us what matters most to you, because it changes what we optimise for

What the first year usually looks like

People consistently underestimate how long rheumatology takes at the start and overestimate how burdensome it becomes later. The first year is the demanding one.

The first appointment

A full history, an examination of joints across the whole body, and usually blood tests ordered at the end. You may leave without a diagnosis, and should leave knowing what is being considered.

The second appointment

Results are reviewed and, in most cases, this is where the diagnosis is made and treatment begins. Disease-modifying treatments take six to twelve weeks to show their full effect, which is the single most important expectation to set at this point. A steroid is often used in the interim to control symptoms while the slower drug takes hold.

The first three to six months

Blood monitoring is most frequent here, often monthly, because the small proportion of people who react badly to a drug generally do so early. Disease activity is scored at intervals, and treatment is escalated if the target is not being met.

Beyond that

Once disease is controlled, visits typically move to every three to six months and monitoring becomes less frequent. Where remission is sustained, careful dose reduction may be possible. It is planned rather than improvised, because stopping treatment abruptly is one of the more common causes of a relapse that is harder to control than the original disease.

PLACEHOLDER: confirm the actual follow-up and monitoring intervals used by this practice and amend the timescales above to match.

What we do not claim

A stated approach is worth more if it also says where it stops.

• We cannot cure most rheumatic disease. Control, often excellent control, is the realistic aim
• No diet, supplement or alternative therapy substitutes for treatment in inflammatory arthritis, though diet genuinely matters in gout
• Not all pain is inflammatory, and treating non-inflammatory pain with immunosuppression helps nobody
• Some diagnoses take months to become clear, and no amount of testing accelerates that
• We will refer elsewhere when another specialty is better placed, and would rather do it early

PLACEHOLDER: this page describes a clinical method and must be reviewed and signed off by the physician, who should confirm that it accurately describes how they actually practise. Confirm the follow-up intervals, the monitoring schedule and the disease activity measures used, and amend anything that does not match reality. A stated approach the practice does not follow is worse than none.