Numerous challenges confront the rheumatologist in identifying the earliest possible time during which the patient will have persistent rheumatoid arthritis (RA) or risk factors for severe RA. The first challenge is that of accurate diagnosis: clinical assessments are nonspecific and current diagnostic criteria lack sensitivity. Further compounding the problem, the patient may not seek medical attention, or may not be referred to a rheumatologist, until symptoms have been present for some time. Studies indicate that initiating treatment with disease modifying antirheumatic drugs (DMARD) as soon as possible after diagnosis produces significant clinical and functional benefit and appears to retard the rate of radiographic progression of erosions. Delaying treatment by as little as 8 or 9 months sets the stage for damage that cannot be reversed.