What Does A Rheumatologist Do?

Welcome Back Rheumatology Fans!What on earth does a Rheumatologist do? What ingredients make up the secret sauce? Watch the video to find out and I have sorted a little summary below if you are strapped for time. Video SummaryWhat actually happens after you refer someone to rheumatology with suspected psoriatic arthritis (PsA)? It’s a question many clinicians ask — particularly because PsA doesn’t come with a neat, definitive diagnostic test.This episode walks through what really goes on behind the clinic door.Psoriatic arthritis is a clinical diagnosis. While investigations can support it, they are often inconclusive. Around 90% of patients will have a negative rheumatoid factor. HLA-B27 is negative in roughly half of cases (higher in axial presentations), and inflammatory markers such as ESR and CRP are only elevated about 50% of the time. Imaging isn’t foolproof either — ultrasound and MRI may show inflammatory changes, but only if the right structures are scanned at the right time.So what are rheumatologists doing differently?Primarily, they are applying highly developed clinical reasoning. The initial consultation looks remarkably similar to a skilled MSK assessment: detailed history, joint examination, skin assessment, pattern recognition. The difference lies in the depth of exposure to inflammatory disease and the synthesis of information across multiple domains.Broadly, three scenarios tend to emerge:* Clinical suspicion + supportive investigations → straightforward diagnosis and initiation of DMARD therapy such as methotrexate.* Strong clinical suspicion but negative tests → cautious treatment trial (NSAIDs, steroid injection) with close follow-up.* Uncertain clinical picture + negative tests → further differentials considered, or a watch-and-wait strategy with review over time.Importantly, there is no “magic blood test.” The real expertise lies in pattern recognition, probabilistic thinking, and appropriately managing uncertainty.For physiotherapists, understanding this process helps refine referrals, manage patient expectations, and appreciate why a definitive answer isn’t always immediate. Rheumatology isn’t about hidden investigations — it’s about high-level clinical reasoning applied consistently and responsibly. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit rheumatologyphysio.substack.com/subscribe