Exactly what RASally says. No doctor is going to be perfect. To me, this one sounds better than the last one. I would follow up on that folic acid. Very much needed when on methotrexate.

I think RASally is correct in that he is trying to control what he can regarding the fatigue. If certain meds contribute to that, then maybe he is thinking along those lines. Develop a list like RASally has. Put down what is important to you. And, know that no one is going to reach all points.

Sounds like you had a better encounter with this one than the last one.

Thanks for your advice Sally and Linda. You guys make a lot of sense. I would like to find out, however, what his definition of remission is. Is it his hope? Is it merely an improvement over where I'm at right now? Is he simply trying to spread some optimism? As for fatigue I'm convinced that many of our rheumatologists don't address our fatigue concerns because they can't treat it. Once again you make sense in your assessment that he may just view fatigue as part of the disease and he will adjust my meds to diminish it. My wife said he never denied that fatigue was a symptom of RA just that some meds aren't good for people with RA because they contribute to fatigue. That's why he doesn't like the Vicodin. He believes it makes me tired and it certainly does if I take it while at work.

I need some time to mull this over. I merely went in looking for a second opinion on treatment options and he completely assumed that I was sticking with him and switching doctors. That very well be the case but I just hope that his assumption isn't a sign of arrogance! He also said that "most of his patients go into remission", not that most people with RA go into remission. That's a but arrogant as well if you ask me.

Speaking of arrogance - both me and my wife felt that he was arrogant but accurate in his treatment plan so I'll add in the MTX, switch to Meloxicam and Tylenol with Codeine for pain as needed. I'll go back in 4 weeks. I may like him better in the future and he may clarify things for me as well. I'm certainly better off with him at this point than the previous rheumy!
I sure wish the was easier! It's bad enough having the disease but finding a doctor who I feel comfortable with shouldn't be this hard! It never was like this with any of my other doctors:(

One more thing that could be significant or may mean nothing. He had a student with him from the local hospital. As a teacher I know I act different while being observed by a colleague. For all I know he was putting on a show for her. I suppose he is worth another visit next month.

I knew I never should have gotten off that darn MTX!!!

But add folic acid to the MTX!!

I like optimistic rheumatologists. But it's fair to tell him you are a realist and prefer not to be too hopeful since you haven't had good luck yet.

Sounds like a good doc for the most part...except forgetting the folic acid.

Forget remission- focus on being at a tolerable level with this disease to be able to do what you need to do and then accept your limitations.
I don't think we'll ever feel pre-RA but I'm happy where I'm at.

I was looking forward to your new doc report.

It sounds like you are somewhat disappointed which I would be also. But the first thing that came to mind is this is a step in the right direction if nothing else.

Did the new doc order any blood work? If so once he sees the tests that he ordered he may see your condition better.

The fatigue - when I speak of it to my doc I don't get much of a response - hardly even an acknowledgement. One thing that is actually nice with me is I always see a PA first before my doc comes in. The PA's seem to be much more forthcoming about a lot of things and have given me some good insight. I think that has been said here already that the fatigue is frustrating to them not knowing how to treat it let alone how severe it is.

I am involved in an extensive ongoing survey for one of the RA organizations - the name slips my mind at the moment. It actually feels good to fill out this survey because it touches on so much that we discuss here. The item in question being fatigue - there are at least 10 questions each time on fatigue, its severity, and its effect on your daily life. So at least with that I know it is recognized by the RA organization community.

The same goes when I mention the pain - no real response. To the point he has never asked me about helping with the pain - thankfully my PCP takes care of that for me. Another point is most docs tend to stay away from prescribing narcotics now with all the new laws and regulations - this may be the case with this new doc also.

I think it's a big step just to get you started on MTX. But as other have said the Folic Acid is a must as far as I know. If you can't get an Rx from the doc at the very least get yourself some OTC. I was started out on 1mg per day so that is a good starting point if you have to get your own until your next visit.

And that word "remission". At my very first appointment the doc did a lot of explaining of the disease to me and also his normal course of action. He said the GOAL was remission but never eluded to me that it was possible or even probable. He said if we can get the disease to stop progressing he would be happy. Who knows - maybe stopping the progression is what is meant by remission?

When is your follow up appointment? Maybe then you both may be a little closer to being on the same page.

Hi Coaltrain,
My follow up is in 4 weeks. The doctor's take on the hydrocodone is that it will add to fatigue so I guess he acknowledges RA fatigue. He likes the codeine route for that reason and because he can give me refills. 30 mg codeine is the Morphine equivalent of 5 mg hydrocodone so at least he gave me pain meds with refills. Codeine is still a narcotic but still at Schedule 3. I do agree that hydrocodone and work do not mix at all and make me tired.

I was wondering from you and anyone else who would like to chime in. I have a doctor called a physiatrist who dealt with my degenerative back disease for the past 4 years and my pain issues. I was wondering if I should pay him a visit just to get his opinion on my current pain issues. I haven't seen him since I got RA because the rheumys were supposedly treating pain issues. At the very least he can document the continued back pain I have and add that documentation to my file should I be in the same place in a year and wanting to apply for disability. He can document my chronic pain as well and I know his records are very good, My short term plan is to return next year and give it another try. I'd love to work for a few more years if possible.
Greg

I'll have to look up what a physiatrist (psysicist?) is or does. My first thought is along with yours that the documentation from a doc concerning the pain would go a long way with any future claims you may have. I must also say that I wouldn't mind any extra help - I am at the edge most days where the pain meds just barely do anything - but from what I've read that is how it is supposed to be and not take the pain totally away.

Myself - I've never been to such a doc.

My wife being a chronic pain sufferer for 10+ years now went to some kind of doc like that once a long time ago. This was a requirement for her to try a nerve stimulation machine of some kind which was supposed to help alleviate her pain. It was an all around bad experience for her unfortunately. Even though we had good insurance at the time this doc demanded we pay $450 up front which put up all kinds of red flags for me. After his evaluation he upped her depression medication to a level which she could not tolerate among other things. So now our PCP takes care of all that for her.

I guess I am kind of lucky in that my PCP (same as my wife's) seems to understand our pain and has been treating us. She tells us we are 2 of a very few that she does this for. Without that we would be out of luck as there is no such thing as a pain clinic or pain doc anywhere around here.

At times I think maybe I should see a doc like this - as much as us guys never want to admit it I do have a hard time dealing with the pain at times - especially in the winter when I am stuck indoors for 4-5 months.

I am for anything that can help Greg. If my PCP recommended I go to such a doc I wouldn't hesitate to go.

Yeah - the class II(?) medications are a pain especially being our doc is 35 miles away and even our pharmacy is 10 miles - makes for some special trips each month which we both hate. But....it is what it is....

I am also very interested in hearing some other comments on this subject as this is an ongoing problem for me.

Stan

I wanted to add after thinking about your post Greg - now that I see how it is with chronic pain that doesn't show - "you look fine!" - I think it would be nice to have some validation of some sort once in a while - if nothing else maybe "proof" that you are in pain?

Pain is such an abstract - I don't like abstracts but something solid to go on.

You're messing with me right Coaltrain? How can any of us truly prove we are in pain? I think we'd all like to think and hope that our doctors take our word for it. I know I sure expect that from them.

Plus a good doctor can see the completely degenerative disc in my back and assume pain. They can see the swelling in my joints and assume pain. That is if they are experienced enough.

Coaltrain, you are dead right that pain is abstract, subjective, about as squishy as it gets. That's one reason many doctors don't like to mess with it. They are quantitative folk, by inclination and by training, and something that cannot be measured, seen, or otherwise accurately measured makes them nuts.

Drug addicts often claim lower back pain to get narcotics, as so many back problems don't show up on imaging. Conversely, every doc has stories about patients whose spinal MRI looks they should be bed-bound who still hike and play some tennis.

The same is true of fatigue.

Greg, you are right that a good doctor, especially one that has a relationship of mutual trust and respect with his/her patients should take what we say seriously. However, I have been patronized, dismissed, suspected of drug-seeking behavior, etc., and it is infuriating. (Especially since I routinely refuse narcotics and have a stupidly high tolerance for pain.) Women of a certain age get it the worst, probably, but men are not immune.

There are people with RA, lupus, fibromyalgia, etc., that have written extensively about "invisible illness" and the burden of hearing various forms of "but you don't look sick" over and over. It's one of the loneliest and most isolating parts of living with an autoimmune disease.

Stan, I didn't see your previous post about pain. I agree, I should probably have my physiatrist document it for me. A phsyiatrist specializes in pain (both chronic and acute) which is why I went to him for my degenerative disc. They specialize in non-surgical approaches to treat the muscular skeletal system. I'm not sure how much he knows about RA but paying him a visit (seeing I saw him for 3 or 4 years) can't hurt. If anything he can note that my disc is still degenerating and that I suffer in pain from that as well as a host of other things. If my RA declines and some RA doctor wants to spend a few years playing guinea pig on my while my employer gets mad at my poor attendance rate he may be able to help me with any paper work I need.
You also mentioned pain meds and how difficult finding a pain clinic may be for some people. In my case it wouldn't be hard to find at all by this new rheumy chose the Tylenol with codeine route not only because he feels I won't be as tired taking it (vs. hydrocodone) but so he can write refills. In fact he did write 3 refills for me as it is still a Schedule 3 med like hydrocodone used to be.
Thanks for your good idea!

Alto, My physiatrist never doubted my pain and restored my declining back to a state of greater functionality. Sure my MRI showed that my lowest disc was as thin as a potato chip but he trusted me as well. I'm not saying this new rheumy doesn't trust me but who knows? I've only seen him once and trust isn't built in one visit. Thanks for sharing!

I'll be curious to see how the Tylenol w/Codine works for you Greg.

I also find the phsyiatrist idea a good one possibly for my wife after reading up a little on what they do. The tough part will be finding such a doc around here. Also my wife is very stubborn about all this after her past bad experiences with these type of specialists so it would be very hard to convince her to go to any other doc than our PCP now.

I'm trying to find a way to help her - she is getting worse and worse because of the tolerance to her pain medication (at the max dose). She had 2 lower back disk surgeries - the last of which she waited too long and the ruptured disk had calcified onto the sciatic nerve which had to be scraped for removal leaving it permanently damaged. What she is going through day after day is nothing in comparison to my RA pain I feel.

A physiatrist may be a good choice for her Stan. I found mine years ago by accident. I called a well respected orthopedic group for back pain and they scheduled me with the physiatrist first. I think that was a better choice than a surgeon. He did all the same tests such as MRIs, X Rays, etc....... He diagnosed me with a herniated disc but didn't think that was the reason for the constant pain and sciatica as the herniation was older and not touching nerves. He also diagnosed me with degenerative disc disease and treated me for such, I walked into his office 4 years ago and basically told him I had pain and numbness daily and that for a man in his late forties my quality of life was suffering. Through a variety of meds and other treatments he had me feeling 99% better within about 6 months. While he did specialize in pain medicine he did a lot more than just prescribing narcotics. I thank him to this day! Of course my back is a degenerative condition and who knows if it will require surgery down the road. Hopefully not! Now I have a progression condition and a degenerative condition. My back pain is no longer daily and I almost never feel the numbness anymore. That area of my back is hurting today but I've switched from Lodine (which was originally the nsaid for my back) then to Celebrex which was even stronger and more effective but causing me to break out in hives so now I'm on Meloxicam which I haven't felt any benefits from yet (I don't think). Not only is my back hurting but my swollen fingers and toes are not doing as well without the Celebrex. Oh well, today is Enbrel day and tomorrow is MTX day!

I haven't tried the tylenol with codeine yet but according to an opiate conversion scale 2 of those tabs has the morphine equivalent of 10 mg of hydrocodone. If it helps without making me tired then I'll be psyched seeing that the hydrocodone made me tired and never fully took away my RA pain anyway.

I'm slow catching up here.
So sorry did not go better.
For lack of better words ( thank you exhaustion & brainfog) he appears to be a step a head of your previous doc.
Yet his comments about meds causing exhaustion & no folic acid would raise red flags.
To be honest with luck fully acknowledged this new dr I found set a new standard with me. The exam alone was nothing at all to anything my previous dr did. Neglect on my part for not looking sooner added to my problems. So learning the hard way I have to say use your intuition. If your unsure go with that feeling.

For the life of me I'll never understand why exhaustion is ignored & not addressed. I've met others in my daily life with RA. Most have no clue what comes with RA. They were relieved to hear they are not alone.
No doctor went over any of the nastiness of this disease.
Come on, we are living proof. It's online everywhere. Ok they may not know the cause but don't deny it & leave the patient in the dark.
Yet depression is listed on those forms we fill out each visit.
Well I'm no expert but sure can't help but wander if it all helps depression a long the way.

I've seen a Physiatrist. He did keep me comfortable. These doctors are underrated I think.
One of many Drs while looking for the cause of my pain & problems. Every single one acknowledged I had injury & pain. Evident when they could not move my arm without gagging, heaving or just plain crying. The cause stayed hidden for 2 yrs.
After years of asking this I've learned. There is no test that is 100% all times. Even with visible pain it's in your head if answers are not quick enough. Women get it worse (no offense).
Spinal caused majority with shoulder kicking in to help.
Took all that time but I did find a doctor who listened. He was in pain management & had seen it all. By that time the damage was permanent. So yes good doctors can make or break. Damaged patients & lives left behind. Don't wish that on another living soul.
You said those keys words " quality of life".
I was informed by a very wise man to use those words when trying to get the point across to doctors. As they are there to preserve & improve quality of life for those who need it.

I've been on pain meds, never ever experienced this exhaustion with anything. No one will convince me these doctors do not hear about exhaustion & brain fog daily. It's insulting at times.
My new RA DR did nod at least as did his assistant when I brought that subject up. I'm going to ask where he stands on these topics.

Perhaps looking at what's out there. Since it can take time to get in consider another try at a new doc. Could always cancel if you decide your comfortable with this one. I guess the question is what do you have to loose?

Since this RA hit my spinal mess is much worse. Especially during flares or if I'm off treatment. Always curious if others experience the same.
Sounds like you had one great doctor you'll find another.
It's just time consuming & frustrating.
Not assuring to hear a resident was in toll. Folic acid plays a big role in prescribing MTX.

Remission? I guess if it were that simple there'd be a lot more of us in remission. That claim raises another red flag.
Coal God bless your wife. I simply could not imagine. I control my mess with injections & procedures. If I did not have that option I'm not sure I could deal with the pain. She's one strong lady.
Sammy