Questions about Endocrinology and Rheumatology Work-Life, Job Outlook, etc.?

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I'm a PGY1 interested in both endocrinology and rheumatology. Since I'm nearing the end of my intern year, I am thinking more seriously about what I really want to do so I can focus on research in the fellowship I am more interested in. If possible, I would appreciate any advice and answers from endocrinologist and rheumatologist fellows/attendings in helping me to figure out where I fit better.

I guess I can separate them out for ease:

Endocrinology
In medical school, the physiology of endocrinology made so much intuitive sense and I really liked it. My exposure, however, to endocrinology is minimal thus far and only includes a week of shadowing in an endocrinology clinic in medical school. I have asked my seniors around about the endocrinology rotation here regarding the sort of pathology they see but I would appreciate your perspective.

1. What is the job market for endocrinology like in the coming years? Will it be difficult to find well-paying jobs in larger cities?
2. What is the distribution of pathology you typically see in fellowship and in outpatient clinic in the community? I understand it will mostly be diabetic management but is there a good access for patients to get newer technologies like closed-loop delivery devices in general or is that more in academic areas? Is there still exposure to interesting endocrine pathologies like ICI endocrinopathies, POEMS, adrenal insufficiency, full blown Cushing's, etc.? Or is that more in academic areas?
3. What is the day-to-day like for an endocrinologist? Are there any inpatient consultations you have to see? What about in academia?
4. I am not comfortable with prescribing hormone therapy as part of care for transgender patients due to my personal beliefs. Will that be an issue in fellowship? Are most programs requiring that as part of training?
5. How intense is the fellowship training?
6. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in endocrinology?

Rheumatology
I really enjoyed learning the pathophysiology of rheumatic diseases in medical school and seeing the clinical manifestations of these diseases during a rotation I spent in a rheumatology clinic in medical school. It ended up being my favorite rotation. I enjoyed the reliance on history and physical examination, the difficult nature of diagnosis, and how satisfying it was to make some unique diagnoses. Unfortunately, our residency does not allow for rotations in rheumatology until late PGY3 and only lasts 2 weeks because it is associated with a private practice clinic that does not have the ability to accommodate for more educational time.

1. What is the job market for rheumatology like in the coming years? One thing I'm wondering about is with the rarer nature of connective tissue disorders compared to diabetes or Grave's disease, is if I can get a good patient load if I want to move to an area that already has rheumatologists or if I move to a rural area that is not well populated?
2. What distribution of pathology do you see in fellowship and as an attending? Is it possible to focus your clinic pathology more towards CTDs/autoimmune disease or will that require staying in academia if I want to see more of those cases? If you are in private practice, is there more of a focus on musculoskeletal disease like OA, FM, osteoporosis, etc. then? Is it hard to build up a patient load in the beginning of your career?
3. I have had some exposure to what rheumatology daily work-life is like but if you could give me a glimpse in to your day-to-day I would appreciate it. Do you see any inpatient consults? What about in academia?
4. How intense is the fellowship training?
5. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in rheumatology?

If you have any other advice, I truly am grateful.

Thank you

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Endocrine here.

There are a number of threads here that have discussed this, you may want to do a search.

The biggest issue I see is that you have an issue with transgender/gender affirming care. While it’s not done by only endocrinology and ca you do endocrine after fellowship without doing it…it would be a concern that someone had a person belief against it and they go into endocrinology. It’s like going into ob/gyn and not believe in birth control… can you do it… yea…do go against the standards of the specialty…yes.

Endocrine is not a high paint specialty, so of that is a consideration, you won’t necessarily find it the norm…ave academic salary is 180-200k…pp avg 250k… can you make 500k … yeah but that is a high high volume or owning a practice or something like that.

Job security is decent… there is a need and demand for endocrine practically everywhere… but just like every specialty, big cities pay less.

You will see a variety of endocrinopathies, but the General Endocrinologist will see mostly diabetes sand thyroid. You can specialize in certain areas, but the more specialized you are then more you will need to be at an academic center.

Would do an endocrine rotation to see if it really is what you think it is.

Would talk to your pd and see if you can get special permission to do rheum earlier to be able to compare…if they m pw you are considering it as a fellowship, they may let you do it earlier.
 
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The biggest issue I see is that you have an issue with transgender/gender affirming care. While it’s not done by only endocrinology and ca you do endocrine after fellowship without doing it…it would be a concern that someone had a person belief against it and they go into endocrinology. It’s like going into ob/gyn and not believe in birth control… can you do it… yea…do go against the standards of the specialty…yes.
Good point

But just like in the USMLE step 1 ethics/ behavioral sciences question, the move then would be to make sure the OP had a partner or someone easily accessible to take care the patient(s) who need gender affirming care. Just like how an OBGYN against abortion or whatever has to do the right thing and make sure the patient who wants it gets easy access to another OBGYN who could take care of the patient (unless its a state that bans it. the law is the law after all)

It's the classic case of "I may not agree with what you say but I will advocate for you as my patient and defend your right to do so"
 
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Good point

But just like in the USMLE step 1 ethics/ behavioral sciences question, the move then would be to make sure the OP had a partner or someone easily accessible to take care the patient(s) who need gender affirming care. Just like how an OBGYN against abortion or whatever has to do the right thing and make sure the patient who wants it gets easy access to another OBGYN who could take care of the patient (unless its a state that bans it. the law is the law after all)

It's the classic case of "I may not agree with what you say but I will advocate for you as my patient and defend your right to do so"

The issue is that your advocacy is veiled under prejudice towards a high risk minority.
 
The issue is that your advocacy is veiled under prejudice towards a high risk minority.
I support my patients who are LGBTQQIP2SA+. I work in NYC after all.
Please see the personal message and let's not get political here on the main thread. We can throw some mud in the personal messages.
I am merely citing what we learned in medical school to the OP as a potential means for the OP to justify to the OP's own beliefs possibly entering endocrinology later on in the OP's career.
 
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I'm a PGY1 interested in both endocrinology and rheumatology. Since I'm nearing the end of my intern year, I am thinking more seriously about what I really want to do so I can focus on research in the fellowship I am more interested in. If possible, I would appreciate any advice and answers from endocrinologist and rheumatologist fellows/attendings in helping me to figure out where I fit better.

I guess I can separate them out for ease:

Endocrinology
In medical school, the physiology of endocrinology made so much intuitive sense and I really liked it. My exposure, however, to endocrinology is minimal thus far and only includes a week of shadowing in an endocrinology clinic in medical school. I have asked my seniors around about the endocrinology rotation here regarding the sort of pathology they see but I would appreciate your perspective.

1. What is the job market for endocrinology like in the coming years? Will it be difficult to find well-paying jobs in larger cities?
2. What is the distribution of pathology you typically see in fellowship and in outpatient clinic in the community? I understand it will mostly be diabetic management but is there a good access for patients to get newer technologies like closed-loop delivery devices in general or is that more in academic areas? Is there still exposure to interesting endocrine pathologies like ICI endocrinopathies, POEMS, adrenal insufficiency, full blown Cushing's, etc.? Or is that more in academic areas?
3. What is the day-to-day like for an endocrinologist? Are there any inpatient consultations you have to see? What about in academia?
4. I am not comfortable with prescribing hormone therapy as part of care for transgender patients due to my personal beliefs. Will that be an issue in fellowship? Are most programs requiring that as part of training?
5. How intense is the fellowship training?
6. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in endocrinology?

Rheumatology
I really enjoyed learning the pathophysiology of rheumatic diseases in medical school and seeing the clinical manifestations of these diseases during a rotation I spent in a rheumatology clinic in medical school. It ended up being my favorite rotation. I enjoyed the reliance on history and physical examination, the difficult nature of diagnosis, and how satisfying it was to make some unique diagnoses. Unfortunately, our residency does not allow for rotations in rheumatology until late PGY3 and only lasts 2 weeks because it is associated with a private practice clinic that does not have the ability to accommodate for more educational time.

1. What is the job market for rheumatology like in the coming years? One thing I'm wondering about is with the rarer nature of connective tissue disorders compared to diabetes or Grave's disease, is if I can get a good patient load if I want to move to an area that already has rheumatologists or if I move to a rural area that is not well populated?
2. What distribution of pathology do you see in fellowship and as an attending? Is it possible to focus your clinic pathology more towards CTDs/autoimmune disease or will that require staying in academia if I want to see more of those cases? If you are in private practice, is there more of a focus on musculoskeletal disease like OA, FM, osteoporosis, etc. then? Is it hard to build up a patient load in the beginning of your career?
3. I have had some exposure to what rheumatology daily work-life is like but if you could give me a glimpse in to your day-to-day I would appreciate it. Do you see any inpatient consults? What about in academia?
4. How intense is the fellowship training?
5. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in rheumatology?

If you have any other advice, I truly am grateful.

Thank you
Rheum here.

We’ve had many recent posts about this so I’d suggest scrolling down this forum to see some of them, where I’ve discussed a lot of this info.

Nevertheless, here are the highlights:

- I love rheumatology.

- I am 100% outpatient and I’ve not seen hospital consults since I was a fellow. I like this because I think hospital work is a pain in the ass, and because I really love outpatient practice. All three of my jobs as a rheumatologist so far have been 100% outpatient.

- in general, demand for rheumatologists is very robust. I’ve worked in the urban Midwest, the semi rural South, and the semi urban Midwest. I’ve never had trouble accruing a patient panel (and quickly) and most of what I see is legit rheumatologic disease and not fibro and OA.

- Osteoporosis is your friend. You’ll appreciate those cases to break up the complex rheumatology throughout the day.

- Fellowship training can me much more pleasant than IM residency. I went to a “highly ranked” program that kicked my ass with a lot of research as well as tons of consult weeks on a very busy consult service, but many of my rheumatology friends had much more chill fellowships. This is not pulm/crit or something. You won’t be doing overnight call shifts and such.

- Academic rheumatology is a topic we’ve rehashed on these boards extensively. The highlights: IMO, it is a ripoff for most rheumatologists. You will generally work 2x harder for 30-50% less pay. Don’t do it unless you have a major love of research AND already have an RO1 or something similar. Most other people who do academic rheumatology will be disappointed and will wash out after 3-5 years.
 
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Endocrine here.

There are a number of threads here that have discussed this, you may want to do a search.

The biggest issue I see is that you have an issue with transgender/gender affirming care. While it’s not done by only endocrinology and ca you do endocrine after fellowship without doing it…it would be a concern that someone had a person belief against it and they go into endocrinology. It’s like going into ob/gyn and not believe in birth control… can you do it… yea…do go against the standards of the specialty…yes.

Endocrine is not a high paint specialty, so of that is a consideration, you won’t necessarily find it the norm…ave academic salary is 180-200k…pp avg 250k… can you make 500k … yeah but that is a high high volume or owning a practice or something like that.

Job security is decent… there is a need and demand for endocrine practically everywhere… but just like every specialty, big cities pay less.

You will see a variety of endocrinopathies, but the General Endocrinologist will see mostly diabetes sand thyroid. You can specialize in certain areas, but the more specialized you are then more you will need to be at an academic center.

Would do an endocrine rotation to see if it really is what you think it is.

Would talk to your pd and see if you can get special permission to do rheum earlier to be able to compare…if they m pw you are considering it as a fellowship, they may let you do it earlier.

Thank you for your reply. I've scoured quite a few threads here from past years. Some of your advice in previous threads was very helpful as well. Just wanted to ask more about how things are nowadays.

I don't want to delve into the specifics of my personal beliefs but I have no issue treating transgender patients when it comes to other diseases like HTN, DM, etc. I just would not want to practice giving cross-sex hormone therapy. Do you know if it's a requirement for training in it for all fellowships? Like the equivalent of an ACGME requirement in IM residency?

What are your thoughts on academic endocrinology and its outlook?

When it comes to money, as long as I can live a comfortable lifestyle without working too hard, I would be content. Money is not a huge motivating factor for me.

I will hopefully get exposure in endocrinology in PGY2 but it usually occurs in the latter half of the year and when it comes to rheumatology, unfortunately, I asked my PD and she shut it down.

Rheum here.

We’ve had many recent posts about this so I’d suggest scrolling down this forum to see some of them, where I’ve discussed a lot of this info.

Nevertheless, here are the highlights:

- I love rheumatology.

- I am 100% outpatient and I’ve not seen hospital consults since I was a fellow. I like this because I think hospital work is a pain in the ass, and because I really love outpatient practice. All three of my jobs as a rheumatologist so far have been 100% outpatient.

- in general, demand for rheumatologists is very robust. I’ve worked in the urban Midwest, the semi rural South, and the semi urban Midwest. I’ve never had trouble accruing a patient panel (and quickly) and most of what I see is legit rheumatologic disease and not fibro and OA.

- Osteoporosis is your friend. You’ll appreciate those cases to break up the complex rheumatology throughout the day.

- Fellowship training can me much more pleasant than IM residency. I went to a “highly ranked” program that kicked my ass with a lot of research as well as tons of consult weeks on a very busy consult service, but many of my rheumatology friends had much more chill fellowships. This is not pulm/crit or something. You won’t be doing overnight call shifts and such.

- Academic rheumatology is a topic we’ve rehashed on these boards extensively. The highlights: IMO, it is a ripoff for most rheumatologists. You will generally work 2x harder for 30-50% less pay. Don’t do it unless you have a major love of research AND already have an RO1 or something similar. Most other people who do academic rheumatology will be disappointed and will wash out after 3-5 years.

Thank you so much. I've seen your posts before as well and found them very helpful. It's nice to hear the demand is still robust and it's easy to get a patient population with true rheumatic disease as opposed to mostly OA/FM/MSK pain.

I honestly like osteoporosis and bone mineral diseases as a whole, so that's no problem for me. It's a good link between rheum and endo as well.

Thanks for the honest depiction of academic rheumatology. The major thing drawing me to academia in either case is just wanting to see difficult to treat, rare, or interesting presentations of disease as opposed to a focus in research. I'm not opposed to research, but I prefer clinical practice to it by far.
 
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I support my patients who are LGBTQQIP2SA+. I work in NYC after all.
Please see the personal message and let's not get political here on the main thread. We can throw some mud in the personal messages.
I am merely citing what we learned in medical school to the OP as a potential means for the OP to justify to the OP's own beliefs possibly entering endocrinology later on in the OP's career.
I have no issues sending a patient to some other physician who gives cross-sex hormone therapy and I have no issues providing other sorts of treatment to transgender patients for their other chronic conditions or acute conditions, as I do in my residency clinic. I just would prefer not to, based on personal beliefs, administer gender-affirming/cross-sex hormone therapy care myself either in fellowship or in practice.
 
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I'm a PGY1 interested in both endocrinology and rheumatology. Since I'm nearing the end of my intern year, I am thinking more seriously about what I really want to do so I can focus on research in the fellowship I am more interested in. If possible, I would appreciate any advice and answers from endocrinologist and rheumatologist fellows/attendings in helping me to figure out where I fit better.

I guess I can separate them out for ease:

Endocrinology
In medical school, the physiology of endocrinology made so much intuitive sense and I really liked it. My exposure, however, to endocrinology is minimal thus far and only includes a week of shadowing in an endocrinology clinic in medical school. I have asked my seniors around about the endocrinology rotation here regarding the sort of pathology they see but I would appreciate your perspective.

1. What is the job market for endocrinology like in the coming years? Will it be difficult to find well-paying jobs in larger cities?
2. What is the distribution of pathology you typically see in fellowship and in outpatient clinic in the community? I understand it will mostly be diabetic management but is there a good access for patients to get newer technologies like closed-loop delivery devices in general or is that more in academic areas? Is there still exposure to interesting endocrine pathologies like ICI endocrinopathies, POEMS, adrenal insufficiency, full blown Cushing's, etc.? Or is that more in academic areas?
3. What is the day-to-day like for an endocrinologist? Are there any inpatient consultations you have to see? What about in academia?
4. I am not comfortable with prescribing hormone therapy as part of care for transgender patients due to my personal beliefs. Will that be an issue in fellowship? Are most programs requiring that as part of training?
5. How intense is the fellowship training?
6. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in endocrinology?

Rheumatology
I really enjoyed learning the pathophysiology of rheumatic diseases in medical school and seeing the clinical manifestations of these diseases during a rotation I spent in a rheumatology clinic in medical school. It ended up being my favorite rotation. I enjoyed the reliance on history and physical examination, the difficult nature of diagnosis, and how satisfying it was to make some unique diagnoses. Unfortunately, our residency does not allow for rotations in rheumatology until late PGY3 and only lasts 2 weeks because it is associated with a private practice clinic that does not have the ability to accommodate for more educational time.

1. What is the job market for rheumatology like in the coming years? One thing I'm wondering about is with the rarer nature of connective tissue disorders compared to diabetes or Grave's disease, is if I can get a good patient load if I want to move to an area that already has rheumatologists or if I move to a rural area that is not well populated?
2. What distribution of pathology do you see in fellowship and as an attending? Is it possible to focus your clinic pathology more towards CTDs/autoimmune disease or will that require staying in academia if I want to see more of those cases? If you are in private practice, is there more of a focus on musculoskeletal disease like OA, FM, osteoporosis, etc. then? Is it hard to build up a patient load in the beginning of your career?
3. I have had some exposure to what rheumatology daily work-life is like but if you could give me a glimpse in to your day-to-day I would appreciate it. Do you see any inpatient consults? What about in academia?
4. How intense is the fellowship training?
5. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in rheumatology?

If you have any other advice, I truly am grateful.

Thank you
Rheum here as well.

I have worked in urban, suburban, rural and semi-rural locations. If you want a job that isn't miserable and just a bunch of chronic pain, fatigue, malaise or other random symptom, then rural and semi-rural are the only options. I would never wish big city rheumatology on my worst enemy. So, if you do decide to do rheumatology, be prepared to either move 1 hour+ outside a major metro or get about 20 mychart messages a week about random symptoms that are non-rheumatic.

And working for an academic or "fakedemic" institution in a big city won't save you from those kinds of referrals, because most places are now "fakedemic." I was a “faculty” at one of these fakedemic places. They operate just like any private hospital but they just call themselves University of [insert state]. The admin will load you up with every garbage referral that your outlying rheumatology colleagues rejected but you'll have to see since you have no power to reject anything.

If one of your priorities is to live and work in a major metropolitan area, then I would not recommend rheumatology. The best you can hope for is to find a gig that's a long but feasible commute. I have several friends that commute 45-50 minutes, but that gets old after a few years.
 
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Rheum here as well.

I have worked in urban, suburban, rural and semi-rural locations. If you want a job that isn't miserable and just a bunch of chronic pain, fatigue, malaise or other random symptom, then rural and semi-rural are the only options. I would never wish big city rheumatology on my worst enemy. So, if you do decide to do rheumatology, be prepared to either move 1 hour+ outside a major metro or get about 20 mychart messages a week about random symptoms that are non-rheumatic.

And working for an academic or "fakedemic" institution in a big city won't save you from those kinds of referrals, because most places are now "fakedemic." I was a “faculty” at one of these fakedemic places. They operate just like any private hospital but they just call themselves University of [insert state]. The admin will load you up with every garbage referral that your outlying rheumatology colleagues rejected but you'll have to see since you have no power to reject anything.

If one of your priorities is to live and work in a major metropolitan area, then I would not recommend rheumatology. The best you can hope for is to find a gig that's a long but feasible commute. I have several friends that commute 45-50 minutes, but that gets old after a few years.
Thank you for your reply. How can you tell if a program is a "fakedemic" program? Are there any red flags or tell-tale signs?

Have you had issues with building up your patient panel when working in rural or semi-rural areas?

Any advice for getting accepted into and choosing a fellowship program for rheumatology?
 
Thank you for your reply. I've scoured quite a few threads here from past years. Some of your advice in previous threads was very helpful as well. Just wanted to ask more about how things are nowadays.

I don't want to delve into the specifics of my personal beliefs but I have no issue treating transgender patients when it comes to other diseases like HTN, DM, etc. I just would not want to practice giving cross-sex hormone therapy. Do you know if it's a requirement for training in it for all fellowships? Like the equivalent of an ACGME requirement in IM residency?

What are your thoughts on academic endocrinology and its outlook?

When it comes to money, as long as I can live a comfortable lifestyle without working too hard, I would be content. Money is not a huge motivating factor for me.

I will hopefully get exposure in endocrinology in PGY2 but it usually occurs in the latter half of the year and when it comes to rheumatology, unfortunately, I asked my PD and she shut it down.



Thank you so much. I've seen your posts before as well and found them very helpful. It's nice to hear the demand is still robust and it's easy to get a patient population with true rheumatic disease as opposed to mostly OA/FM/MSK pain.

I honestly like osteoporosis and bone mineral diseases as a whole, so that's no problem for me. It's a good link between rheum and endo as well.

Thanks for the honest depiction of academic rheumatology. The major thing drawing me to academia in either case is just wanting to see difficult to treat, rare, or interesting presentations of disease as opposed to a focus in research. I'm not opposed to research, but I prefer clinical practice to it by far.
You will see plenty of exotic pathology in rural areas. One thing I’ve realized after working in medicine for a while is that big city tertiary care is actually largely something that the upper middle class and rich utilize. In more rural areas, you will find plenty of people that can’t or won’t drive to a tertiary care center for their unusual illness.

Some of the rarest and most complex pathology I’ve ever seen was seen in the rural south or Midwest. And I trained at a major, very name brand quaternary referral center everyone here would recognize.
 
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I support my patients who are LGBTQQIP2SA+. I work in NYC after all.
Please see the personal message and let's not get political here on the main thread. We can throw some mud in the personal messages.
I am merely citing what we learned in medical school to the OP as a potential means for the OP to justify to the OP's own beliefs possibly entering endocrinology later on in the OP's career.

Lets me rephase. Not yours/you. But rather the people who say go get your health elsewhere because they disagree are often not good people.
 
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Be honest with yourself. The training is done in academic centers. Almost all are liberal as they come. Could they tolerate you not doing trans hormonal training? Possible, but you will be a pariah for sure. Why do this to yourself? Just go into rheumatology and don't deal with this
 
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Agreed.

The OP should realize that being a physician and the Hippocratic oath is more than just for show in medical school. You can't abandon your patients and "turf it" to someone else. during residency/ fellowship training, the patients you are assigned are "your patients." While the patient is billed under the attending, it's not exactly ethical to pick and choose which patients you want to see when you are part of a health system.

I mean if you did Endocrinology then moved to a more conservative region and opened your own personal private practice, you could just hang up a sign that says "sorry I am not trained in trans-hormonal therapy. here are some my colleagues who could help you." technically if you have never 'established a contract' with a patient, you are not abandoning anyone. this scenario isn't exactly the bake shop scenario (i don't want to get off on a tangent too much ...) as you have plausible deniability with not being trained in hormonal therapy like that.

At the end of the day, if the whole hormonal thing does not fit with your belief system then contemplate another subspecialty. There are lots of other excellent ones out there!


Edit: I am more conservative leaning but I am not a MAGA nut. I support all my patients as a physician should but I bend no knee to the cancel culture woke mafia crowd. In fact, this is one reason why I left the hospital system. The corporations are deathly afraid of being cancelled (and I get it... revenue streams and reputation and all) Fortunately, all patients I see have been pleasant individuals and no different than any other patient I see. At the end of the day we are all human beings after all.
 
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Agreed.

The OP should realize that being a physician and the Hippocratic oath is more than just for show in medical school. You can't abandon your patients and "turf it" to someone else. during residency/ fellowship training, the patients you are assigned are "your patients." While the patient is billed under the attending, it's not exactly ethical to pick and choose which patients you want to see when you are part of a health system.

I mean if you did Endocrinology then moved to a more conservative region and opened your own personal private practice, you could just hang up a sign that says "sorry I am not trained in trans-hormonal therapy. here are some my colleagues who could help you." technically if you have never 'established a contract' with a patient, you are not abandoning anyone. this scenario isn't exactly the bake shop scenario (i don't want to get off on a tangent too much ...) as you have plausible deniability with not being trained in hormonal therapy like that.

At the end of the day, if the whole hormonal thing does not fit with your belief system then contemplate another subspecialty. There are lots of other excellent ones out there!
While I agree with you in terms of what happens during medical training, I think this is much less of a big deal in the real world than people are making it sound here.

I support LGBTQ patients. My wife is a member of the LGBTQ community. However, doctors outside academia choose certain things to see/not see all the time. You are (generally) allowed to decline consults/referrals as a physician. In my specialty, there are many rheums who do not see fibromyalgia, CFS, or even OA. I’ve personally encountered several endos who don’t do transgender work. My suspicion is that many (most?) real world endos don’t actually do it, just like how there is a very tiny fraction of OBs that do elective abortions. Transgender hormonal management is actually a relatively small niche patient population, and what I’ve heard from my trans patients is that most of them have gone to doctors who specifically focus on this, and not just your local endocrinologist.

Again, I support LGBTQ patients - when I lived in the semi rural south I was one of the few doctors in the area who was willing to see them. The endo at my practice in the south didn’t see them. Moral judgement aside, he was overrun with diabetes and thyroid consults (aka endo bread and butter) and was doing just fine for himself. I didn’t like it, but nobody was coming after this guy about it and he had plenty of referrals to see.
 
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While I agree with you in terms of what happens during medical training, I think this is much less of a big deal in the real world than people are making it sound here.

I support LGBTQ patients. My wife is a member of the LGBTQ community. However, doctors outside academia choose certain things to see/not see all the time. You are (generally) allowed to decline consults/referrals as a physician. In my specialty, there are many rheums who do not see fibromyalgia, CFS, or even OA. I’ve personally encountered several endos who don’t do transgender work. My suspicion is that many (most?) real world endos don’t actually do it, just like how there is a very tiny fraction of OBs that do elective abortions. Transgender hormonal management is actually a relatively small niche patient population, and what I’ve heard from my trans patients is that most of them have gone to doctors who specifically focus on this, and not just your local endocrinologist.

Again, I support LGBTQ patients - when I lived in the semi rural south I was one of the few doctors in the area who was willing to see them. The endo at my practice in the south didn’t see them. Moral judgement aside, he was overrun with diabetes and thyroid consults (aka endo bread and butter) and was doing just fine for himself. I didn’t like it, but nobody was coming after this guy about it and he had plenty of referrals to see.
This is changing as older endos retire and there are younger people in endocrinology. Remember endocrine isn’t a big money maker… people go into ot because of the subject matter… and because there is such a lack of transgender care, many outside of endocrine are doing… a bit similar to diabetes… not every pt woth dm sees an endocrinologist… because there is no way that care can be done by the few endocrinologists out there in practice.
And previously transgender care wasn’t as prominent in endocrinology ( or other specialties) , but it is becoming more and more so and is becoming a part of the training…and unlike other specialties, endocrinology fellowship are at academic institutions.
Just like life is different as an attending vs being a resident, so it is for being a fellow vs a practicing endocrinologist…we all get experience in everything in endo, but once out in practice, you can gear yourself to different areas…for example, I really don’t see that much diabetes… actually don’t like it that much and my specialty is calcium metabolism and osteoporosis. But you betcha I had a diabetes clinic every week as a fellow…not like I could say that I didn’t want to treat diabetes pts because of personal beliefs…
It may not be a hurdle l, but it’s something he needs to think about…and he has interests in something that doesn’t test his beliefs.
 
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I'm a PGY1 interested in both endocrinology and rheumatology. Since I'm nearing the end of my intern year, I am thinking more seriously about what I really want to do so I can focus on research in the fellowship I am more interested in. If possible, I would appreciate any advice and answers from endocrinologist and rheumatologist fellows/attendings in helping me to figure out where I fit better.

I guess I can separate them out for ease:

Endocrinology
In medical school, the physiology of endocrinology made so much intuitive sense and I really liked it. My exposure, however, to endocrinology is minimal thus far and only includes a week of shadowing in an endocrinology clinic in medical school. I have asked my seniors around about the endocrinology rotation here regarding the sort of pathology they see but I would appreciate your perspective.

1. What is the job market for endocrinology like in the coming years? Will it be difficult to find well-paying jobs in larger cities?
2. What is the distribution of pathology you typically see in fellowship and in outpatient clinic in the community? I understand it will mostly be diabetic management but is there a good access for patients to get newer technologies like closed-loop delivery devices in general or is that more in academic areas? Is there still exposure to interesting endocrine pathologies like ICI endocrinopathies, POEMS, adrenal insufficiency, full blown Cushing's, etc.? Or is that more in academic areas?
3. What is the day-to-day like for an endocrinologist? Are there any inpatient consultations you have to see? What about in academia?
4. I am not comfortable with prescribing hormone therapy as part of care for transgender patients due to my personal beliefs. Will that be an issue in fellowship? Are most programs requiring that as part of training?
5. How intense is the fellowship training?
6. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in endocrinology?

Rheumatology
I really enjoyed learning the pathophysiology of rheumatic diseases in medical school and seeing the clinical manifestations of these diseases during a rotation I spent in a rheumatology clinic in medical school. It ended up being my favorite rotation. I enjoyed the reliance on history and physical examination, the difficult nature of diagnosis, and how satisfying it was to make some unique diagnoses. Unfortunately, our residency does not allow for rotations in rheumatology until late PGY3 and only lasts 2 weeks because it is associated with a private practice clinic that does not have the ability to accommodate for more educational time.

1. What is the job market for rheumatology like in the coming years? One thing I'm wondering about is with the rarer nature of connective tissue disorders compared to diabetes or Grave's disease, is if I can get a good patient load if I want to move to an area that already has rheumatologists or if I move to a rural area that is not well populated?
2. What distribution of pathology do you see in fellowship and as an attending? Is it possible to focus your clinic pathology more towards CTDs/autoimmune disease or will that require staying in academia if I want to see more of those cases? If you are in private practice, is there more of a focus on musculoskeletal disease like OA, FM, osteoporosis, etc. then? Is it hard to build up a patient load in the beginning of your career?
3. I have had some exposure to what rheumatology daily work-life is like but if you could give me a glimpse in to your day-to-day I would appreciate it. Do you see any inpatient consults? What about in academia?
4. How intense is the fellowship training?
5. What sort of things do you recommend I do to have a strong application to get into some better programs? What are some good or better programs in rheumatology?

If you have any other advice, I truly am grateful.

Thank you
Only replying for point 4 of endocrine. GAHT is very popular right now and many fellowships are really interested in it as it is relatively easy to add to thier program. There is also a certain portion of applicants who that is the entire focus of thier app. This is despite it being a relatively small part of endocrine and not a part at all 5 plus years ago. That said you can match with restrictions but it will cause discrimination/limitations as many programs have leadership that are vested in it beyond just the medical care portion. That said if your up front about your restrictions and apply broadly it is still possible to match.
 
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