Rheum vs pulm crit

[prn123]

Hi all,

I’m an IM resident at a university-affiliated community hospital. I want to apply for fellowship, however, am torn between rheum and pulm crit. I do realize that these are two very different career paths and a lot of people would not be choosing between two of them. On the other hand, I feel that they have a lot in common: multisystem approach and diagnostic challenges.
I like that rheum has seen a lot advances recently. These days monoclonal antibodies targeting certain steps of immune response are very common therapeutic options in many conditions not only in rheum but in other fields.
At the same time, sometimes I feel that rheum may become boring over time, especially, in the outpatient setting.

I like pulm crit because it combines very interesting physiology with rapid application of your skills and assessment of the outcomes of your patients at the bedside. Pulm as a subspecialty is very complex and versatile. But some people argue that crit docs can burn out over time.
Would like to get your opinions on that? Any input from rheum fellows/attendings about the prospects of their field? Would also appreciate the same input from pulm folks..

Thank you

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[rokshana]

Hi all,

I’m an IM resident at a university-affiliated community hospital. I want to apply for fellowship, however, am torn between rheum and pulm crit. I do realize that these are two very different career paths and a lot of people would not be choosing between two of them. On the other hand, I feel that they have a lot in common: multisystem approach and diagnostic challenges.
I like that rheum has seen a lot advances recently. These days monoclonal antibodies targeting certain steps of immune response are very common therapeutic options in many conditions not only in rheum but in other fields.
At the same time, sometimes I feel that rheum may become boring over time, especially, in the outpatient setting.

I like pulm crit because it combines very interesting physiology with rapid application of your skills and assessment of the outcomes of your patients at the bedside. Pulm as a subspecialty is very complex and versatile. But some people argue that crit docs can burn out over time.
Would like to get your opinions on that? Any input from rheum fellows/attendings about the prospects of their field? Would also appreciate the same input from pulm folks..

Thank you

This really is more about whether you want to be primarily outpt or inpt...yes the pulm aspect will give some outpt opportunities.

Also which would you rather have acutely ill or chronically ill....that too is a determining factor.

 

[prn123]

This really is more about whether you want to be primarily outpt or inpt...yes the pulm aspect will give some outpt opportunities.

Also which would you rather have acutely ill or chronically ill....that too is a determining factor.

Thank you for your input, rokshana. I like both outpatient and inpatient aspects of medicine..don’t mind doing primarily outpatient as long as it’s not primarily a monotonous job..In addition, would like to do some procedures..I guess the prospects of the field I will be going to are also very important to me. Of course, no one knows what is going to happen in 10-20 years but there are definitely some trends..

 

[bronx43]

The problem with rheumatology is that what your practice will look like will depend HEAVILY on where you're located. Unlike most other specialists, our diseases are exceedingly rare. Real autoimmune disease is rarer than most people think. Unless you're in a truly underserved area where there are less than 1 rheumatologist per 70k residents, then you will have a hard time filling your clinic with non-BS.

However, the only places with that kind of distribution is BFE, where no one wants to live. Your other option is to live in a desirable location but work in academia, for which the salary is trash.

For pulm/CC, there doesn't exist this sort of discrepancy in terms of the actual medicine that you are practicing. CC is CC and most of pulm is pretty similar - save for some rare ILDs.

 

[tartesos]

Fibromyalgia patients end up referred to rheumatology.... simmer on that for a minute.


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[Animalcules]

Rheum will never become boring. It an onslaught of unique and rewarding cases that will challenge you.

 

[deleted1022594]

This is the reason why I could never do rheum. You will see lots of fibro referrals, and even though you won’t see them again as follow ups, you still have to see these patients once and that’s a bad day for me. I just can’t listen to pain everywhere complaints all day long. You need to tolerate/enjoy the mundane things you will see in the speciality of choice. Every specialty has their own fibro-like patients.

 

[COTA2Phys]

Hi all,

I’m an IM resident at a university-affiliated community hospital. I want to apply for fellowship, however, am torn between rheum and pulm crit. I do realize that these are two very different career paths and a lot of people would not be choosing between two of them. On the other hand, I feel that they have a lot in common: multisystem approach and diagnostic challenges.
I like that rheum has seen a lot advances recently. These days monoclonal antibodies targeting certain steps of immune response are very common therapeutic options in many conditions not only in rheum but in other fields.
At the same time, sometimes I feel that rheum may become boring over time, especially, in the outpatient setting.

I like pulm crit because it combines very interesting physiology with rapid application of your skills and assessment of the outcomes of your patients at the bedside. Pulm as a subspecialty is very complex and versatile. But some people argue that crit docs can burn out over time.
Would like to get your opinions on that? Any input from rheum fellows/attendings about the prospects of their field? Would also appreciate the same input from pulm folks..

Thank you

I don’t have much to offer, but to say that I am torn between the exact two specialties. I’m glad that I’m not the only one.


Sent from my iPhone using SDN mobile

 

[prn123]

The problem with rheumatology is that what your practice will look like will depend HEAVILY on where you're located. Unlike most other specialists, our diseases are exceedingly rare. Real autoimmune disease is rarer than most people think. Unless you're in a truly underserved area where there are less than 1 rheumatologist per 70k residents, then you will have a hard time filling your clinic with non-BS.

However, the only places with that kind of distribution is BFE, where no one wants to live. Your other option is to live in a desirable location but work in academia, for which the salary is trash.

For pulm/CC, there doesn't exist this sort of discrepancy in terms of the actual medicine that you are practicing. CC is CC and most of pulm is pretty similar - save for some rare ILDs.

Thank you for your comment, bronx43! I would like to practice in SoCal. Some affiliation with university hospital would be preferred since I think rheum is very “cerebral” field that requires exposure to academic medicine if you want to challenge yourself from time to time and see interesting presentations of autoimmune conditions. Vasculitis is one of my favorite ones However, I do agree that a lot of referrals are inappropriate and can be managed easily by PCP (provided they have time for it). I’m just curious why chose rheum as your career...if you could choose right now and had tons of research in any IM subspecialty, which one would you pick for your fellowship?

 

[prn123]

Fibromyalgia patients end up referred to rheumatology.... simmer on that for a minute.


Sent from my iPhone using SDN

Actually, I don’t think this is a big issue. Think about it: patients get referred to rheum. They do their assessment which includes pretty much the standard set of questions. They order standard labs. They schedule a follow-up appt to discuss the results. If no autoimmune stuff, then you simply send the patient back to PCP recognizing, of course, that their pain is real, however, not related to autoimmune conditions.Plus, When patients start demanding opioids you can simply respond by saying that you are treating pain with anti inflammatory medications only. They can see pain management team for opioid requests. Yes, you may see a lot of patients like this, but it’s just pattern recognition rather than a headache.
With pulm clinic, I would say seeing a COPD patients that continues to smoke despite all the recommendations to quit, might feel even worse for a doctor who is taking career of that patient..just my thoughts

 

[prn123]

Rheum will never become boring. It an onslaught of unique and rewarding cases that will challenge you.

Are a you a rheum fellow? If yes, what are your goals after the fellowship?academia vs private practice?

 

[prn123]

This is the reason why I could never do rheum. You will see lots of fibro referrals, and even though you won’t see them again as follow ups, you still have to see these patients once and that’s a bad day for me. I just can’t listen to pain everywhere complaints all day long. You need to tolerate/enjoy the mundane things you will see in the speciality of choice. Every specialty has their own fibro-like patients.

Ikr. What did you end up doing? Do you enjoy your working in your field?

 

[prn123]

I don’t have much to offer, but to say that I am torn between the exact two specialties. I’m glad that I’m not the only one.


Sent from my iPhone using SDN mobile

Haha. My coresidents and attentings think that these are two very different fields..I don’t know..I just think these are the only fields I can see myself doing long term..

 

[bronx43]

Thank you for your comment, bronx43! I would like to practice in SoCal. Some affiliation with university hospital would be preferred since I think rheum is very “cerebral” field that requires exposure to academic medicine if you want to challenge yourself from time to time and see interesting presentations of autoimmune conditions. Vasculitis is one of my favorite ones However, I do agree that a lot of referrals are inappropriate and can be managed easily by PCP (provided they have time for it). I’m just curious why chose rheum as your career...if you could choose right now and had tons of research in any IM subspecialty, which one would you pick for your fellowship?

I chose it because I thought the same thing everyone does... interesting cases, good lifestyle, decent money.
if I can go back I would do GI for those reasons I stated in my previous post - ubiquitous diseases.

 

[jdh71]

Hi all,

I’m an IM resident at a university-affiliated community hospital. I want to apply for fellowship, however, am torn between rheum and pulm crit. I do realize that these are two very different career paths and a lot of people would not be choosing between two of them. On the other hand, I feel that they have a lot in common: multisystem approach and diagnostic challenges.
I like that rheum has seen a lot advances recently. These days monoclonal antibodies targeting certain steps of immune response are very common therapeutic options in many conditions not only in rheum but in other fields.
At the same time, sometimes I feel that rheum may become boring over time, especially, in the outpatient setting.

I like pulm crit because it combines very interesting physiology with rapid application of your skills and assessment of the outcomes of your patients at the bedside. Pulm as a subspecialty is very complex and versatile. But some people argue that crit docs can burn out over time.
Would like to get your opinions on that? Any input from rheum fellows/attendings about the prospects of their field? Would also appreciate the same input from pulm folks..

Thank you

You do plenty of rheum in pulmonary. A lot of the vasculitis and CTD world manifests most noticeably through the lungs (or pulmonary artery) with significant symptoms. You’ll do the work up. You’ll find the diagnosis. Sometimes you won’t find ENOUGH of a diagnosis for rheum and you manage clear and obvious rheumatological disease without the specific antibodies that lets rheum pretend there is no disease and you’ll manage the methotrexate, cellcept, azathioprine, etc. You’ll give rituxan. Hell you might be giving rituxan or cytoxan in the ICU to a young vasculitis patient.

If you like rheum. Pulm has plenty. If you like both the hospital and the clinic this is a clear no brainer, pulm/crit. If you get burned out in the hospital you just do pulm.

I’m scaling back my time in SDN very significantly for a awhile. Maybe for good. If you have any other questions I’m fine with PM.

Good luck.

 

[prn123]

You do plenty of rheum in pulmonary. A lot of the vasculitis and CTD world manifests most noticeably through the lungs (or pulmonary artery) with significant symptoms. You’ll do the work up. You’ll find the diagnosis. Sometimes you won’t find ENOUGH of a diagnosis for rheum and you manage clear and obvious rheumatological disease without the specific antibodies that lets rheum pretend there is no disease and you’ll manage the methotrexate, cellcept, azathioprine, etc. You’ll give rituxan. Hell you might be giving rituxan or cytoxan in the ICU to a young vasculitis patient.

If you like rheum. Pulm has plenty. If you like both the hospital and the clinic this is a clear no brainer, pulm/crit. If you get burned out in the hospital you just do pulm.

I’m scaling back my time in SDN very significantly for a awhile. Maybe for good. If you have any other questions I’m fine with PM.

Good luck.

Thank you very much for your input! Will PM you.

 

[mdjo]

I'm a rheum fellow and I really like pulm--I seriously considered whether I could stomach the CC aspect to get to the interesting Pulm side of things. For me, CC is both really hard and stressful and kind of boring (just neverending sepsis and respiratory failure) so the worst of both worlds. I decided suffering through CC was not worth it for me and went for rheum. For me it's not just about interesting diseases, it's also about getting to know your patients as people and building long-term relationships with them. That's by far my favorite part of medicine and of rheumatology. Almost all of my patients seem to like me and it's really unusual for someone to get mad at me in clinic (not intended as a brag, it's more that rheumatologists just make people feel better and people are really grateful for that). Very energizing and rewarding.

 

[prn123]

I chose it because I thought the same thing everyone does... interesting cases, good lifestyle, decent money.
if I can go back I would do GI for those reasons I stated in my previous post - ubiquitous diseases.

Would like to PM you but your profile “has limitations”..

 

[prn123]

I'm a rheum fellow and I really like pulm--I seriously considered whether I could stomach the CC aspect to get to the interesting Pulm side of things. For me, CC is both really hard and stressful and kind of boring (just neverending sepsis and respiratory failure) so the worst of both worlds. I decided suffering through CC was not worth it for me and went for rheum. For me it's not just about interesting diseases, it's also about getting to know your patients as people and building long-term relationships with them. That's by far my favorite part of medicine and of rheumatology. Almost all of my patients seem to like me and it's really unusual for someone to get mad at me in clinic (not intended as a brag, it's more that rheumatologists just make people feel better and people are really grateful for that). Very energizing and rewarding.

Thank you for your input, mdjio. It’s quite unusual to see somebody who loves pulm over CC..from what I’ve heard a lot of pulm/crit got attracted to the field through CC part and then developed interest in pulm..
It seems like you have the right attitude while taking care of your patients. What is rewarding in rheum is that in most cases it’s not your patient’s “fault” that they developed an autoimmune condition (there are of course risks associated with certain habits, ex. Smoking and RA) but in most cases we dont’t really know what triggers an autoimmune “aggression” and patients seem to be truly involved in their care.
What do you think about job prospects for rheum graduates? Financial aspect as well? (I know rheum are still close to the bottom in terms of compensation, however, I assume this might change with some recent advances in the field)..

 

[tartesos]

Actually, I don’t think this is a big issue. Think about it: patients get referred to rheum. They do their assessment which includes pretty much the standard set of questions. They order standard labs. They schedule a follow-up appt to discuss the results. If no autoimmune stuff, then you simply send the patient back to PCP recognizing, of course, that their pain is real, however, not related to autoimmune conditions.Plus, When patients start demanding opioids you can simply respond by saying that you are treating pain with anti inflammatory medications only. They can see pain management team for opioid requests. Yes, you may see a lot of patients like this, but it’s just pattern recognition rather than a headache.
With pulm clinic, I would say seeing a COPD patients that continues to smoke despite all the recommendations to quit, might feel even worse for a doctor who is taking career of that patient..just my thoughts

Seems like your mind is made up.


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[prn123]

Seems like your mind is made up.


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I just don't care much about fibro. It's a headache for PCPs. What is more concerning to me is what bronx45 mentioned in his first comment..." exceedingly rare diseases...

 

[bronx43]

I just don't care much about fibro. It's a headache for PCPs. What is more concerning to me is what bronx45 mentioned in his first comment..." exceedingly rare diseases...

Exactly. Fibro is whatever
However, low prevalence of rheumatic diseases is a huge problem. In fact, the incidence of RA is actually decreasing due to less tobacco use in society. If I had done the math prior to fellowship, I would have picked something else. With this push for increasing the rheumatology workforce, it may not end up well for future fellows...

The only way a lot of private practice rheumatologists get by is by “loosening” their diagnostic criteria. It’s a rampant problem out there...

 

[Animalcules]

Exactly. Fibro is whatever
However, low prevalence of rheumatic diseases is a huge problem. In fact, the incidence of RA is actually decreasing due to less tobacco use in society. If I had done the math prior to fellowship, I would have picked something else. With this push for increasing the rheumatology workforce, it may not end up well for future fellows...

The only way a lot of private practice rheumatologists get by is by “loosening” their diagnostic criteria. It’s a rampant problem out there...

I don't fully agree with this. Yes, maybe 0.01% less cases of RA, sure. At the same time, the flood gates are open at academic centers because of of all the immune checkpoint carnage that our oncology friends are creating at an exceedingly fast pace. All disease that is new and did not exist. There is a large push for targeting preclinical autoimmunity. These will become patients in the next decades. There is a need for more rheumatologist if the wait times even in the best served states is 2-3 months for new patients. It's insanity. Nobody will be out of a job for the next 30 years which is really what you should care about. Also, life without call is much better.

 

[prn123]

I don't fully agree with this. Yes, maybe 0.01% less cases of RA, sure. At the same time, the flood gates are open at academic centers because of of all the immune checkpoint carnage that our oncology friends are creating at an exceedingly fast pace. All disease that is new and did not exist. There is a large push for targeting preclinical autoimmunity. These will become patients in the next decades. There is a need for more rheumatologist if the wait times even in the best served states is 2-3 months for new patients. It's insanity. Nobody will be out of a job for the next 30 years which is really what you should care about. Also, life without call is much better.

Good point about checkpoint inhibitors! Definitely, we will be seeing more and more of immune-targeted therapy and, therefore, one would assume that rheum should be in demand.

 

[Animalcules]

You do plenty of rheum in pulmonary. A lot of the vasculitis and CTD world manifests most noticeably through the lungs (or pulmonary artery) with significant symptoms. You’ll do the work up. You’ll find the diagnosis. Sometimes you won’t find ENOUGH of a diagnosis for rheum and you manage clear and obvious rheumatological disease without the specific antibodies that lets rheum pretend there is no disease and you’ll manage the methotrexate, cellcept, azathioprine, etc. You’ll give rituxan. Hell you might be giving rituxan or cytoxan in the ICU to a young vasculitis patient.

If you like rheum. Pulm has plenty. If you like both the hospital and the clinic this is a clear no brainer, pulm/crit. If you get burned out in the hospital you just do pulm.

I’m scaling back my time in SDN very significantly for a awhile. Maybe for good. If you have any other questions I’m fine with PM.

Good luck.

Mmmm, you seem to be a special kind of critical care doc, no offense. I have not seen many PCCM physicians who feel comfortable throwing around these drugs. Maybe if you specialize in ILD and have done this for a long time. I see a lot of pulse-dose steroids, incomplete workup, inappropriate workup (not blaming them, just not their field of expertise, hence there is the field of rheumatology), and then comfort measures when the pulse is not working after 7 days in the MICU. Very few rheumatologist will rely on autoantibodies to make a diagnosis, so I think your characterization is a little off and maybe these "obvious rheumatological diseases" are not so rheumatic after all? More realistic scenario: patient is sick as f, admitted to MICU, intubated, someone wonders if rheumatological on rounds or an antibody comes back, rheum is consulted, makes diagnosis, decides on treatment, this is then given by the MICU. This may be different at your MICU, but this is my experience.

 

[bronx43]

I don't fully agree with this. Yes, maybe 0.01% less cases of RA, sure. At the same time, the flood gates are open at academic centers because of of all the immune checkpoint carnage that our oncology friends are creating at an exceedingly fast pace. All disease that is new and did not exist. There is a large push for targeting preclinical autoimmunity. These will become patients in the next decades. There is a need for more rheumatologist if the wait times even in the best served states is 2-3 months for new patients. It's insanity. Nobody will be out of a job for the next 30 years which is really what you should care about. Also, life without call is much better.

It's way more than 0.01% based on several studies. Given how tobacco is implicated in rheumatoid pathophysiology, it's certainly not a surprising trend.

Lol, at checkpoint inhibitors... this is how you know rheumatologists are desperate and have to scrape the bottom of the barrel. I trained at an institution with one of the top cancer centers, and we probably did more oncology volume than most other academic centers. These complications are basically just at academic centers. You won't sniff this in private practice.
Furthermore, the prevalence of true ARTHRITIS (needing rheum expertise) induced by checkpoint inhibitors is unclear. Arthralgia are much more common, and guess what? Heme/onc are capable of treating those themselves. The majority of the patients respond to NSAIDs and low dose pred. What do YOU bring to the table as a rheumatologist to these cases? Very little. Sure, there's the rare few cases where you actually need to add a DMARD, but this isn't the norm.

Other non-MSK manifestations of check point inhibitors go to the specialists of the organ they manifest in. Rheum not needed.

2-3 months? Wait times in my city are barely a month. Less if you have some interesting serologies.

 

[bronx43]

Mmmm, you seem to be a special kind of critical care doc, no offense. I have not seen many PCCM physicians who feel comfortable throwing around these drugs. Maybe if you specialize in ILD and have done this for a long time. I see a lot of pulse-dose steroids, incomplete workup, inappropriate workup (not blaming them, just not their field of expertise, hence there is the field of rheumatology), and then comfort measures when the pulse is not working after 7 days in the MICU. Very few rheumatologist will rely on autoantibodies to make a diagnosis, so I think your characterization is a little off and maybe these "obvious rheumatological diseases" are not so rheumatic after all? More realistic scenario: patient is sick as f, admitted to MICU, intubated, someone wonders if rheumatological on rounds or an antibody comes back, rheum is consulted, makes diagnosis, decides on treatment, this is then given by the MICU. This may be different at your MICU, but this is my experience.

Wait, you haven't seen many pulm use cellcept, mtx, and azathioprine? Where do you work, breh?

 

[Animalcules]

It's way more than 0.01% based on several studies. Given how tobacco is implicated in rheumatoid pathophysiology, it's certainly not a surprising trend.

Lol, at checkpoint inhibitors... this is how you know rheumatologists are desperate and have to scrape the bottom of the barrel. I trained at an institution with one of the top cancer centers, and we probably did more oncology volume than most other academic centers. These complications are basically just at academic centers. You won't sniff this in private practice.
Furthermore, the prevalence of true ARTHRITIS (needing rheum expertise) induced by checkpoint inhibitors is unclear. Arthralgia are much more common, and guess what? Heme/onc are capable of treating those themselves. The majority of the patients respond to NSAIDs and low dose pred. What do YOU bring to the table as a rheumatologist to these cases? Very little. Sure, there's the rare few cases where you actually need to add a DMARD, but this isn't the norm.

Other non-MSK manifestations of check point inhibitors go to the specialists of the organ they manifest in. Rheum not needed.

2-3 months? Wait times in my city are barely a month. Less if you have some interesting serologies.

You can play a lot with the numbers and you have to take them with a grain of salt, in my opinion. Comparing an RA diagnosis from 1970 (prior to anti-CCP) is not the same as in 2000. With better imaging and assays, we may be making more accurate diagnoses rather than lumping PsA, chronic CPPD, etc under seronegative RA. With regards to incidence of RA, overall burden of disease is increasing as people get older and we make them live longer on effective DMARDs:
Safiri S et al. Global, regional and national burden of rheumatoid arthritis 1990–2017: a systematic analysis of the Global Burden of Disease study 2017. Annals of the Rheumatic Diseases 2019;78:1463-1471.

The checkpoint inhibitors and combinations are here to stay. At least the arthritis seems to be chronic in many cases, not talking about arthalgias. Now ICI is given to people with even previously perceived contraindications and ever more diagnoses and then pipelines are under full pressure. I think I will see the day when I have more patients with irAEs in clinic than garden variety rheumatic disease. Wait for it. I have yet to see the oncologist give more than naproxen.

I'm not saying you are wrong about everything, but we seems to have very different experiences in the same field.

 

[bronx43]

You can play a lot with the numbers and you have to take them with a grain of salt, in my opinion. Comparing an RA diagnosis from 1970 (prior to anti-CCP) is not the same as in 2000. With better imaging and assays, we may be making more accurate diagnoses rather than lumping PsA, chronic CPPD, etc under seronegative RA. With regards to incidence of RA, overall burden of disease is increasing as people get older and we make them live longer on effective DMARDs:
Safiri S et al. Global, regional and national burden of rheumatoid arthritis 1990–2017: a systematic analysis of the Global Burden of Disease study 2017. Annals of the Rheumatic Diseases 2019;78:1463-1471.

The checkpoint inhibitors and combinations are here to stay. At least the arthritis seems to be chronic in many cases, not talking about arthalgias. Now ICI is given to people with even previously perceived contraindications and ever more diagnoses and then pipelines are under full pressure. I think I will see the day when I have more patients with irAEs in clinic than garden variety rheumatic disease. Wait for it. I have yet to see the oncologist give more than naproxen.

I'm not saying you are wrong about everything, but we seems to have very different experiences in the same field.

Our oncologists give pred all the time. Most cases of irAEs don’t need a rheumatologist. I think that much is seen at most academic centers.

Is it possible that rheum clinics may one day be the hub for these complications? I mean, it’s possible one day we will all be brains in a jar uploaded to virtual reality. I wouldn’t bet on it though.

Honestly, I wouldn’t have done this field again, and I would caution anyone considering it.

 

[Animalcules]

Our oncologists give pred all the time. Most cases of irAEs don’t need a rheumatologist. I think that much is seen at most academic centers.

Is it possible that rheum clinics may one day be the hub for these complications? I mean, it’s possible one day we will all be brains in a jar uploaded to virtual reality. I wouldn’t bet on it though.

Honestly, I wouldn’t have done this field again, and I would caution anyone considering it.

That's fair to say. I would pick rheum again, and again, and again. I do like zebra though and they find me.

 

[bronx43]

That's fair to say. I would pick rheum again, and again, and again. I do like zebra though and they find me.

I have zebras too, but it's rare... hence why they're zebras. If you somehow claim that you have all the zebras, well then I don't believe you based on statistics.

I hate having to sit through 20 nonsense consults to get one real case. Most other specialties don't have this issue.

Are you done with training yet? If not, are you staying in academia?

Oh, don't even get me started on academic salaries for rheum - they must expect all the academic rheumatologists to share a 1 BR flat somewhere.

 

[jdh71]

Mmmm, you seem to be a special kind of critical care doc, no offense. I have not seen many PCCM physicians who feel comfortable throwing around these drugs. Maybe if you specialize in ILD and have done this for a long time. I see a lot of pulse-dose steroids, incomplete workup, inappropriate workup (not blaming them, just not their field of expertise, hence there is the field of rheumatology), and then comfort measures when the pulse is not working after 7 days in the MICU. Very few rheumatologist will rely on autoantibodies to make a diagnosis, so I think your characterization is a little off and maybe these "obvious rheumatological diseases" are not so rheumatic after all? More realistic scenario: patient is sick as f, admitted to MICU, intubated, someone wonders if rheumatological on rounds or an antibody comes back, rheum is consulted, makes diagnosis, decides on treatment, this is then given by the MICU. This may be different at your MICU, but this is my experience.

Your experience is definitely not my experience. I also trained with a few of the gods of ILD. I have no problems with the big bad scary drugs. A physician also needs to stand in the gap for patients when they literally can't get any other help - I'm no cowboy and would love input from a rheum I trust and gets it but . . . - you do what you need to do and I've gotten good at it.

I've not been impressed by community rheum. When I say obvious, I mean it. They do rely solely on specific antibodies for diagnosis. If the ANA is 1:1280, there is fibrosis on CT, restriction on PFT, and life altering symptoms, despite there being no confirming antibody, there is obvious rheum disease present. I get told ALL THE TIME that there is nothing rheumatological going on in this situation. In the ivory tower world of academia (I notice you are a fellow) you can actually find rheumatologists with more open minds. Hell, you can find a consult rheum service. The wait for my patients is also often 4 months, EVEN IF I call and ask for sooner. I've picked up a few antisynthetase syndromes by sending the blood to national jewish or Mayo Clinic, and then RE-referring asking if they would NOW like to help? I actually had one joker say he couldn't and said my medicaid patient (it is a natural law that if you get bad rheum ILD you will also not have a lot of money or resources) needed to go to the Mayo Clinic. FFS. Brain worms!

I know you want to knee jerk defend your field, but there is a lot of horse**** in the community. If you find me painting too broad of a brush, ok, fair enough criticism. I am, however, reacting to my experience. If you leave the academic world, DON'T be that doc.

 

[mdjo]

Thank you for your input, mdjio. It’s quite unusual to see somebody who loves pulm over CC..from what I’ve heard a lot of pulm/crit got attracted to the field through CC part and then developed interest in pulm..
It seems like you have the right attitude while taking care of your patients. What is rewarding in rheum is that in most cases it’s not your patient’s “fault” that they developed an autoimmune condition (there are of course risks associated with certain habits, ex. Smoking and RA) but in most cases we dont’t really know what triggers an autoimmune “aggression” and patients seem to be truly involved in their care.
What do you think about job prospects for rheum graduates? Financial aspect as well? (I know rheum are still close to the bottom in terms of compensation, however, I assume this might change with some recent advances in the field)..

I've been job hunting for the last few months, mostly looking at academic and academic-adjacent positions. I picked a handful of cities that worked for me and my partner and it has been very easy for me to get interviews and offers. Offers have ranged from 180s to 240s for academic starting. My friends going into PP have also had an easy time (even those with geographic restrictions) and are getting offers from 230s to 280s. I had one friend go into pharma from fellowship and is making 400+. I think it's a great time to be a rheumatologist and shouldn't be hard to get a job in all but the most saturated markets.

 

[bronx43]

Your experience is definitely not my experience. I also trained with a few of the gods of ILD. I have no problems with the big bad scary drugs. A physician also needs to stand in the gap for patients when they literally can't get any other help - I'm no cowboy and would love input from a rheum I trust and gets it but . . . - you do what you need to do and I've gotten good at it.

I've not been impressed by community rheum. When I say obvious, I mean it. They do rely solely on specific antibodies for diagnosis. If the ANA is 1:1280, there is fibrosis on CT, restriction on PFT, and life altering symptoms, despite there being no confirming antibody, there is obvious rheum disease present. I get told ALL THE TIME that there is nothing rheumatological going on in this situation. In the ivory tower world of academia (I notice you are a fellow) you can actually find rheumatologists with more open minds. Hell, you can find a consult rheum service. The wait for my patients is also often 4 months, EVEN IF I call and ask for sooner. I've picked up a few antisynthetase syndromes by sending the blood to national jewish or Mayo Clinic, and then RE-referring asking if they would NOW like to help? I actually had one joker say he couldn't and said my medicaid patient (it is a natural law that if you get bad rheum ILD you will also not have a lot of money or resources) needed to go to the Mayo Clinic. FFS. Brain worms!

I know you want to knee jerk defend your field, but there is a lot of horse**** in the community. If you find me painting too broad of a brush, ok, fair enough criticism. I am, however, reacting to my experience. If you leave the academic world, DON'T be that doc.

The reason why community rheum doesn't want to touch these cases is that rheum is actually a bunch of nonsense. We don't really have much more expertise in any of this than our organ-specific colleagues, and there are only a small handful of drugs at our disposal. Shhhh don't tell anyone that though. We rheumatologists have to keep up the appearance.

 

[bronx43]

I've been job hunting for the last few months, mostly looking at academic and academic-adjacent positions. I picked a handful of cities that worked for me and my partner and it has been very easy for me to get interviews and offers. Offers have ranged from 180s to 240s for academic starting. My friends going into PP have also had an easy time (even those with geographic restrictions) and are getting offers from 230s to 280s. I had one friend go into pharma from fellowship and is making 400+. I think it's a great time to be a rheumatologist and shouldn't be hard to get a job in all but the most saturated markets.

The job search isn't the problem. I have recruiters calling me every other week for jobs. The bigger problem is that PP rheum is basically fibro, OA, and making up fake disease. The closer you are to a major metro, the more this statement is true. Out in the boonies, you can probably have mostly real disease.

Check out the math here. According to most epidemiological studies and ACR itself, there are about 1.5 million people in the US with RA.

There are 5000+ practicing rheumatologists in this country, which means if we divide the number of RA by the number of rheum, each doc has 300 patients with RA. As a private practice rheumatologist, I'm going to tell you that even the part time rheumatologists out here have WAY more than 300 RA patients - most have double or triple that number. Where do they all come from? Oh, that's right. A lot of these people don't actually have disease.

The number of true psoriatic arthritis, AS, and SLE are even fewer.

Basically, what's happening is that people are making "soft" diagnoses (to put it gently). I take away more diagnoses from people than I actually diagnose.

OP, do pulm/CC.

 

[jdh71]

The reason why community rheum doesn't want to touch these cases is that rheum is actually a bunch of nonsense. We don't really have much more expertise in any of this than our organ-specific colleagues, and there are only a small handful of drugs at our disposal. Shhhh don't tell anyone that though. We rheumatologists have to keep up the appearance.

I keep trying to pull away from SDN but I did want to respond to this.

I wouldn’t characterize rheum as nonsense. And the chronic management of rheum ILD for instance is the usual treatment of the underlying rheum disorder. I know I’m always happy to help or directly manage any flares in my own organ but the long term treatment needs the nuanced opinion of a rheum trained rheumatologist.

 

[FohBay]

The job search isn't the problem. I have recruiters calling me every other week for jobs. The bigger problem is that PP rheum is basically fibro, OA, and making up fake disease. The closer you are to a major metro, the more this statement is true. Out in the boonies, you can probably have mostly real disease.

Check out the math here. According to most epidemiological studies and ACR itself, there are about 1.5 million people in the US with RA.

There are 5000+ practicing rheumatologists in this country, which means if we divide the number of RA by the number of rheum, each doc has 300 patients with RA. As a private practice rheumatologist, I'm going to tell you that even the part time rheumatologists out here have WAY more than 300 RA patients - most have double or triple that number. Where do they all come from? Oh, that's right. A lot of these people don't actually have disease.

The number of true psoriatic arthritis, AS, and SLE are even fewer.

Basically, what's happening is that people are making "soft" diagnoses (to put it gently). I take away more diagnoses from people than I actually diagnose.

OP, do pulm/CC.

bronx43, it sounds like you are quite unhappy with your career choice. Would you mind sharing your current work set up? Academic vs private, inner city vs suburbs vs rural?

And thoughts about going into primary care or hospitalist?

 

[bronx43]

I keep trying to pull away from SDN but I did want to respond to this.

I wouldn’t characterize rheum as nonsense. And the chronic management of rheum ILD for instance is the usual treatment of the underlying rheum disorder. I know I’m always happy to help or directly manage any flares in my own organ but the long term treatment needs the nuanced opinion of a rheum trained rheumatologist.

But what I’m trying to tell you is that they usually don’t know better than a well trained pulmonologist. I trained at a large academic center (ivory tower type) and I would trust the pulmnologists more with any "possible rheumatology crossovers" than the rheumatologists. And most of the time if things don’t fit nicely into a “rheumatic” diagnosis, most rheum would refuse to take over management.

 

[bronx43]

bronx43, it sounds like you are quite unhappy with your career choice. Would you mind sharing your current work set up? Academic vs private, inner city vs suburbs vs rural?

And thoughts about going into primary care or hospitalist?

I'm PP in an rural-ish underserved area, but making a move back to academia. I have more real disease than my friends in metros, but it's still pretty egregious.

Personally, I would never do PCP or hospitalist. Academia is the right fit for me.

 

[jdh71]

But what I’m trying to tell you is that they usually don’t know better than a well trained pulmonologist. And most of the time if things don’t fit nicely into a “rheumatic” diagnosis, then most would refuse to take over management.

You really don’t think you have a more nuanced opinion on dosing and titration of immunomodualating drugs and when to switch. The best monitoring while on those medications? In my practice I am managing far fewer patients on these drugs than you are in yours. I will have to respectfully disagree that the rheumatologist isn’t the best for the chronic management of the underlying disease EVEN IF the main manifestations are in my organ.

 

[bronx43]

You really don’t think you have a more nuanced opinion on dosing and titration of immunomodualating drugs and when to switch. The best monitoring while on those medications? In my practice I am managing far fewer patients on these drugs than you are in yours. I will have to respectfully disagree that the rheumatologist isn’t the best for the chronic management of the underlying disease EVEN IF the main manifestations are in my organ.

Well, ideally I would want an ILD specialist to manage, which we had a handful at my institution. They would be the best ones.

But if I had to pick between a general pulm who rarely sees ILD and rheum, I guess I would have to go with rheumatology...

 

[jdh71]

Well, ideally I would want an ILD specialist to manage, which we had a handful at my institution. They would be the best ones.

But if I had to pick between a general pulm who rarely sees ILD and rheum, I guess I would have to go with rheumatology...

ILD that is idiopathic requires the pulmonologist.

ILD that exists because of underlying rheumatology condition should definite have the rheumatologist managing the underlying disease. It matters little if it’s main manifestation is in the lungs.

And it’s not like the pulmonologist stops seeing these rheum ILD patients. Choice of disease modulating agents is totally, completely, and appropriately in the wheelhouse of the rheumatologist.

 

[bronx43]

ILD that is idiopathic requires the pulmonologist.

ILD that exists because of underlying rheumatology condition should definite have the rheumatologist managing the underlying disease. It matters little if it’s main manifestation is in the lungs.

And it’s not like the pulmonologist stops seeing these rheum ILD patients. Choice of disease modulating agents is totally, completely, and appropriately in the wheelhouse of the rheumatologist.

If we are talking about clearcut rheumatic diseases like RA, scleroderma, myositis, then I agree. But a lot (perhaps even most) are not clearcut including the example you brought up. For those, i prefer the pulmonologist.

 

[jdh71]

If we are talking about clearcut rheumatic diseases like RA, scleroderma, myositis, then I agree. But a lot (perhaps even most) are not clearcut including the example you brought up. For those, i prefer the pulmonologist.

Well. There won’t always be an antibody to make the a nifty diagnosis in otherwise pretty clear clinical rheum disease.

I think you are wrong here. But I see little need to spend any time arguing or being negative about it. Just to be clear. I’m not trying to be disrespectful. But I need rheum to think more outside neat and tidy boxes. Much of medicine isn’t “textbook” no? I’m trying not to be cynical but I can’t help but think community rheum is saying “no” because it’s not “easy”. Without trying too precious and sanctimonious, I think our patients deserve better.

The last word is yours if you want it.

 

[Animalcules]

The reason why community rheum doesn't want to touch these cases is that rheum is actually a bunch of nonsense. We don't really have much more expertise in any of this than our organ-specific colleagues, and there are only a small handful of drugs at our disposal. Shhhh don't tell anyone that though. We rheumatologists have to keep up the appearance.

You sound bitter for some reason. Rheumatology makes a lot of sense when you integrate clinical observation with understanding of disease pathways (although primitive compared to fields that rely on black and white data from sequencing/genetics). I'm not sure how rheumatology is taught everywhere, but it is certainly not non-sense. If you feel like you have no leg up diagnosing and treating complex immunological diseases, I'm very confused.

 

[bronx43]

You sound bitter for some reason. Rheumatology makes a lot of sense when you integrate clinical observation with understanding of disease pathways (although primitive compared to fields that rely on black and white data from sequencing/genetics). I'm not sure how rheumatology is taught everywhere, but it is certainly not non-sense. If you feel like you have no leg up diagnosing and treating complex immunological diseases, I'm very confused.

Let me clarify. It's not nonsense.. that was hyperbole. What is IT is completely and utterly unknown, and I find it unfulfilling that our diseases are so poorly understood to the point which we can barely define WHAT is our disease? So, instead, we try to diagnose and treat in a very shaman-istic way. And because of this shamanistic approach, it leads to hacks out there who over-diagnose for financial purposes.

 

[tacowithgreensauce]

op,

i also was like you when I started off residency.

I was very conflicted between pulm/cc and rheum myself.

i’ve been told many times that i fit more of the “crit care doc” personality, but i ultimately chose rheum and i’m very excited to start fellowship.

and i think it is an under appreciated point that academia is not indicative of real world practice, but i guess you could say that about every field of medicine.

for better or worse i am knowingly going into rheum with the understanding i am going to see way too much fibromyalgia, oa, gout/pseudo gout, and a bunch bs.

animalcules and bronx

you guys are definitely some of the rheum posters that i look up to, so i appreciate the insight both the good and the bad.

 

[prn123]

op,

i also was like you when I started off residency.

I was very conflicted between pulm/cc and rheum myself.

i’ve been told many times that i fit more of the “crit care doc” personality, but i ultimately chose rheum and i’m very excited to start fellowship.

and i think it is an under appreciated point that academia is not indicative of real world practice, but i guess you could say that about every field of medicine.

for better or worse i am knowingly going into rheum with the understanding i am going to see way too much fibromyalgia, oa, gout/pseudo gout, and a bunch bs.

animalcules and bronx

you guys are definitely some of the rheum posters that i look up to, so i appreciate the insight both the good and the bad.

Thanks for sharing your journey to the fellowship. I guess I also have that "crit care doc" personality

 

[tacowithgreensauce]

Thanks for sharing your journey to the fellowship. I guess I also have that "crit care doc" personality

take my advice with a grain of salt because i havent walked the walk as an attending:

everyone says you burn out on crit care and pulm is suppose to be the “fall back” when you get older. As I’m finishing up pgy3, I’ve already started to realize the lines, codes, goals of care talks, emergent procedures, patient on pressors/ecmo/etc don’t excite me like they use to.

so for me when i was comparing apples to oranges, i decided i’d rather see rheum patients (fibro and all) in my twilight years as opposed to pulmonary patients

i will likely have a different opinion once i become a grizzled attending, but i am willing to take the pay cut to pursue something I find enjoyable (even including the bread and butter stuff in rheum. not just the “once in a blue-moon ivory tower type of stuff”).

i’ll be stuck at work once i’m an attending. might as well try and enjoy it.

i guess my only advice is to make sure you do enough rheum rotations to make sure you can bear/handle the fibros, the quacks, bread & butter. academic medicine (especially the inpatient side) will often feel like it, but not everything is vasculitis, mixed connective tissue, experimental xyz.

 

[prn123]

take my advice with a grain of salt because i havent walked the walk as an attending:

everyone says you burn out on crit care and pulm is suppose to be the “fall back” when you get older. As I’m finishing up pgy3, I’ve already started to realize the lines, codes, goals of care talks, emergent procedures, patient on pressors/ecmo/etc don’t excite me like they use to.

so for me when i was comparing apples to oranges, i decided i’d rather see rheum patients (fibro and all) in my twilight years as opposed to pulmonary patients

i will likely have a different opinion once i become a grizzled attending, but i am willing to take the pay cut to pursue something I find enjoyable (even including the bread and butter stuff in rheum. not just the “once in a blue-moon ivory tower type of stuff”).

i’ll be stuck at work once i’m an attending. might as well try and enjoy it.

i guess my only advice is to make sure you do enough rheum rotations to make sure you can bear/handle the fibros, the quacks, bread & butter. academic medicine (especially the inpatient side) will often feel like it, but not everything is vasculitis, mixed connective tissue, experimental xyz.

Thank you for your comment. I do realize that there is no good or bad career pathway. It all comes down to what makes you happy or, more correctly, what makes you feel less bored.