We thank Dr. Goldman for his interest in our article. We would like to respond to his concern that the PGA and PrGA are not equivalent.
We agree that the clinical judgment of a trained rheumatologist is an important part of treating a patient with rheumatoid arthritis. However, although most evaluators will be rheumatologists, due to the constraints of a modern rheumatology practice, many physicians employ the services of nonphysicians, including physician assistants and nurse practitioners. No data exist to demonstrate that these nonphysician providers are less able to discriminate levels of disease activity than physicians. We would argue that it is important for the same trained assessor to monitor a patient over time due to the interobserver variability seen in assessments of global disease activity, as well as joint counts. However, this assessor need not be a physician if he or she is adequately trained and working closely with a rheumatologist. In drafting these recommendations, we were mindful not to create a scenario where the ability of a rheumatologist to employ such staff would be limited.