Friday, 21 Sep 2018

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A Rheumatology State of Mind

A 2013 study reported that people from Denmark were the happiest. Reasons were postulated, but it was suggested it was because their expectations were so low. In 2012, a Medscape survey of US physicians revealed rheumatology as the most satisfying of medical specialties. This came as a surprise to many as rheumatologists see themselves as the Rodney Dangerfields of medical specialists. 

I’m sure it irks other rheums to fill out career/job forms only to find rheumatology and obstetric paleontology as the only “unlisted” medical specialties. Ever try to explain to your high school friends what exactly a rheumatologist is or does? No, we are not interior decorators or purveyors of rumors.  A rheumatologist is an internist or pediatrician who is qualified by training and experience in the diagnosis and treatment of arthritis, musculoskeletal disorders and disease of immune dysregulation. The reasons why many choose or are so passionate about this specialty is easily evident. Ask any rheumatologist – do you enjoy your job? You’ll be encouraged by their responses.

Rahbar et al presented their survey of nearly 180 trainees at the 2009 ACR annual meeting. They found three factors that strongly influenced a rheumatology career choice: 1) Time (work hours, call, control); 2) Money (salary, opportunities, prestige, less litigation); and 3) Personal fit and intellectual interest. They claimed the ACR recruiting efforts that emphasize “bench to bedside” correctly targeted those intellectually interested enough to be drawn into rheumatology.

In 2009 I surveyed 449 US and Canadian rheumatologists, the majority of whom were male and in practice >15 yrs.  Nearly 36% made the decision to go into rheumatology during medical school and 48% decided during their 2nd or 3rd year of residency. More than half were inspired by a mentor or teacher and one-third by their rheumatology rotation.  Compared to when they started rheumatology, most rheums are proud that they now have fewer disabled patients, fewer surgeries, less X-ray damage and more remissions than decades ago. Although some lament the low income compared to other specialties, only 24% are dissatisfied with their incomes.

There was uniform consensus that rheumatology was a perfect blend of internal medicine and immunology. As practicing rheumatologists they claimed job satisfaction because of challenging patients, the right mix of patients (young and old) and physician quality of life. Problem-solving, quality patient interactions and the potential to improve patient quality of life with advances in therapeutics stood out as reasons for their job satisfaction. Like the earlier UK survey, 87% would again choose rheumatology as a career.

Rheumatology is a family friendly specialty, evidenced by a high number noting the importance of their home life. Over 40% of new rheumatologists are female, many of whom will go into academia, federal jobs (VA, FDA, NIH, etc.) or take private practice jobs where they can job share or work half-time. Past ACR president Jim O’Dell said rheums are happy because “...we are in control of our lives, practice, and time. Therefore, most of us know our children’s names”. 

Surveyed rheumatologists offered the following advice to those who may be considering rheumatology as a career:

“This may be the most exciting era of rheumatology ever with rapid advances in basic, translational and clinical research.”

“Rheumatologists are the true "sleuths" of medicine. We deal with diseases that often have very subtle findings, may be extremely uncommon and are often the ones that could be considered diagnostic challenges that "stump" the other specialties. We have the most appreciative patients and the chronicity of the diseases results in us truly becoming a part of the patient's family. Our new therapies really make a difference in the lives of people who, in the past, have told "you have an incurable disease; sell everything and get a nursing home bed, because that is where you will be in two years.” 

“I have never had a boring day. I learn something new every day. No two patients are the same.” 

“The practice of pediatric rheumatology is very broad and consequently I have many interactions with colleagues in other subspecialties. Pediatric rheumatologists are a collegial group. Having the opportunity to know patients and families over years is very rewarding. The rapid rate of change in the therapeutic armamentarium is exciting... the potential of curing patients now exists. Be a pediatric rheumatologist. It is the best job in all of medicine.”

“The practice of rheumatology is a wonderful blend of internal medicine, musculoskeletal medicine, and clinical immunology. Our diagnoses are often established with a good history and physical examination coupled with serologic tests and various imaging modalities. Biologic therapy has dramatically affected rheumatology patient's treatment and quality of life as well as rheumatologist's practice satisfaction. The practice of rheumatology is always intellectually challenging, enables physician-patient relationships, and allows for a predominantly outpatient practice. This career can be satisfying in a full-time or part-time practice. There are many opportunities for rheumatologists in private practice, clinical trials practice, academic medicine and research.”

“You will stay busy in a rheum practice and enjoy what you do.”

“If you have chosen medicine, rheumatology is the most satisfying integration of all you have learned. I consider my specialty the "super-internist" where the buck stops when diagnosis has not been found. Take good care of your patients and your nights and weekends are mostly free.”

“Fascinating patients with the opportunity to be a detective and make a difference.”

“Great specialty for thinkers.”

“Two of my 3 sons are rheumatologists.”

To see more on my “Careers in Rheumatology Survey”, click here.

Rheumatology draws a special kind of thinker. I find it interesting that rheumatologists have great clarity, ease and optimism about what most practitioners view as voodoo puzzles of aches, pains and complex systemic problems with abnormal serologies. 

Our field needs future problem-solving practitioners and leaders who enjoy quality patient relationships and who wish to be lifetime learners, teachers and researchers. Our diseases are highly prevalent and there are many great achievements and discoveries that have yet to occur. If you like challenge, patient care and rapidly evolving science that benefits patients, you should be a rheumatologist.  

Cole Porter once wrote, ”do that voodoo that you do so well. For you do something to me that nobody else can do.” – this seems to define the rheumatologist. 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.