*What is unique or special about this specialty?*
I’m gonna break this down into pros and cons:
Pros of rheumatology:
- You can be 100% outpatient (I dislike inpatient work)
- Life is simple. One practice environment. See the patients, write the notes, go home. No hospital rounding.
- If you’re in a PP, you have the advantage of largely being able to set your own boundaries without a lot of pushback or admin BS.
- Income potential can be very good in PP rheumatology. I made about $750k last year working 4.5 days a week.
- Rheumatology isn’t cookbook medicine. There are many situations where three competent rheumatologists could see the same patient and come up with three different (yet equally reasonable) diagnoses and treatment plans. As a rheumatologist, you have more latitude to make diagnoses and choose treatments than in many other specialties.
- Rheumatology can be complex and cerebral, which means you get to actually use your brain to figure out interesting patient situations. It’s common to be sent a patient with a lot of unusual symptoms who has already been evaluated by ID, Heme/onc, allergy, etc - what say you, rheumatology? Good diagnostic skills are critical, as is a broad knowledge of medicine, because you will often make diagnoses that don’t necessarily fall under the umbrella of rheumatology.
- Physical exam still matters in rheumatology, which I enjoy.
- You can help patients. The newer meds in rheumatology are really gamechanging for a lot of folks with RA, SLE, PsA etc.
Cons:
- Rheumatology is one of these specialties where lots of other specialties dump their trash. There seems to be a lot of confusion among PCPs and the general medical community about what rheumatologists actually do (and, in turn, what is and isn’t an appropriate rheumatology consult). As a rheumatologist, you can expect to see a lot of patients sent in by doctors who seem to think that you’re an orthopedist, a pain management doctor, a psychiatrist, a sports medicine doctor, and so on. (Please send weird new rashes to dermatology first; please don’t send me a failed back syndrome patient to “see if there is anything that can be done”; I don’t have a secret potion for OA as a rheumatologist that nobody else in medicine has; please stop checking ANAs in old people with osteoarthritis, the +ANA isn’t why they have joint pain; etc etc.) A lot of my time is spent screening out BS consults, and then dealing with seeing the BS consults that snuck through the screening process. I’d say that even after screening, probably only 50% of the consults that get sent in are appropriate rheumatology patients (and that would be about 20-30% if I wasn’t screening). Dealing with a bunch of inappropriate consults, as well as patients’ anger/frustration that goes along with telling these folks that you can’t really help them and that they probably never should have been sent to you in the first place, gets a bit tiring.
- It can be complex and cerebral, which means some cases are time consuming and mentally draining.
- Because our patients are often so complex, our visits are longer than in many specialties and our documentation is also lengthy and time consuming.
- We do a lot of prior auths and have to do a lot of “care coordination” etc, again because of patient complexity. It’s a specialty where you really need good office staff to deal with the busywork.
- There are a lot of “grey zones” and vagueness in rheumatology, which means patients are sometimes frustrated that you can’t deliver a precise diagnosis for them.
- A fair number of rheumatology patients have a certain kind of personality…one that is either clingy and needy or strangely overbearing and demanding. (Sometimes all of the above.) The core issue with all of these types of patients is *anxiety*, which for whatever reason is very prevalent among rheumatology patients. Dealing with all these anxious/obnoxious patients on a daily basis can definitely wear you down a bit.
*What other specialties did you consider and why did you pick this one?*
ID, Heme-onc. I really thought I’d be an oncologist for most of residency - shortly before the deadline for fellowship apps, I did a rheumatology fellowship and it changed everything.
*What challenges will this specialty face in the next 10 years?*
Meh. The ACR and rheumatology brain trust will tell you that there is a massive shortfall of rheumatologists because so many rheumatologists have retired, the population is aging, etc. In reality, a lot of the “aging population” who want to see a rheumatologist just have osteoarthritis, which isn’t really a good reason to see a rheumatologist…
*What are common practice settings for this specialty?*
Outpatient. Most community rheumatologists are 100% outpatient, although you usually can do some inpatient work if you want (most of us don’t). Tertiary rheumatologists spend more time in the hospital.
*How challenging or easy is it to match in this specialty?*
Harder than it used to be. It’s become more competitive, now that word has gotten out about the good lifestyle and decent income potential. It’s now above endo/renal/ID/geriatrics in competitiveness etc, and slightly below cards/pulm/Heme onc.
*What excites you most about your specialty in the next 5, 10, 15 years from now?*
The biologics and other new treatments keep getting better and better.
*Does your specialty currently use or do you foresee the incorporation of technology such as Artificial Intelligence?*
I think AI is going to be a threat to any physician eventually. Not sure this is any better or worse in rheumatology vs other specialties.
*What are some typical traits to be successful in this specialty? (For example, organization skills, work independently)*
You need to be detail oriented, well versed in general internal medicine, and like working up complex situations/distinguishing signal from noise.
*What does a typical workday consist of in your specialty?*
Outpatient clinic. I could round in the hospital too if I wished.
*What is the career progression for your specialty?*
Be a doctor?
How has your work impacted your life dynamics? What is your work-life balance?
Work life balance has been fabulous. I work outpatient only 4.5 days a week, zero call, zero rounding. Last year I made about $750k. Where else in medicine can you do that? Derm, maybe?
*How does healthcare policy impact your specialty?*
We do a lot of prior auths. A lot of time is spent dealing with getting testing and meds authorized for patients. Also, declining CMS and insurance reimbursements arguably affect us more than many other specialties; because our histories are so long and our patients so complex, there is an upper limit on how many pts we can see each day and still do a good job. For me this is about 18-22 at most, preferably less. It’s not a specialty where you can just pack more patients onto your schedule without really cutting corners.
Rheumatology is really a good specialty overall. I’d pick it again. Lifestyle and income have been great. However, you need the right job - one that lets you call the shots in your clinic, doesn’t make you round in the hospital, lets you screen consults, and doesn’t make you see an inordinate number of pts every day.
