Rheumatology? ID?

[bernieout]

I’m a US IMG applying for fellowship this cycle. I have decent step scores (~230s), some case report posters mostly rheum but a few ID/rheum overlap, and am at a community program where the closest rheumatology exposure that we rotate with is a private practice clinic about an hour away. My residency has no research opportunities and very few QI anything and has not been support with me do anything in that realm or even going to conferences out of state or away rotations.

I have always really liked rheumatology since med school. The diseases and the unknown excite me. I like the diagnostic challenge and the pathophys/pharmacologics. Lifestyle is a huge bonus since I have a really sick kid. Loved the elective in residency and got a really good LOR (but again from someone in private practice, not some big shot researcher).

So I’m applying this cycle but I didn’t realize how competitive things are nowadays. In hindsight I should’ve looked more into it but the match rates and how many unfilled spots there are is daunting. I’ve been going to a bunch of program websites and the majority have their fellows coming from top programs a lot better than mine with publications in residency or even med school. I don’t want to become a physician scientist or anything, just a regular rheumatologist seeing patients in the office.

The second specialty I always liked is ID. At least to me there’s a similar diagnostic flow to ID and you also have to have a good understanding of IM and clinical diagnosis because sometimes the differential is broad like for those cases where the hospitalists consult onc, ID, and rheum for FUO or a super high ESR and CRP that they don’t know what to do with. Lots of cool opportunistic infections and having quick treatment responses is honestly more satisfying.

ID seems to be a lot easier getting into. Bunch of places went unmatched. Current fellows on program websites seem more like my level.

I wouldn’t hate ID if I had to do it, it’s just not my first choice because of how much I like rheumatology, having to do much more inpatient, and how overworked the docs at least in my hospital seem. Doesn’t help that ID bread and butter cases like cellulitis and diabetic foot infections are pretty boring to me while I actually enjoy dealing with even OA and gout.

I’m also wondering how the job outlook for these two specialties are. I’m supporting a family too so I have to consider finances in my decision too. I absolutely do not want to be a hospitalist or PCP or any other specialty.

I probably should have thought this through better before this application cycle beginning but just been dealing with a lot personally these last couple years.

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[bronx43]

I’m a US IMG applying for fellowship this cycle. I have decent step scores (~230s), some case report posters mostly rheum but a few ID/rheum overlap, and am at a community program where the closest rheumatology exposure that we rotate with is a private practice clinic about an hour away. My residency has no research opportunities and very few QI anything and has not been support with me do anything in that realm or even going to conferences out of state or away rotations.

I have always really liked rheumatology since med school. The diseases and the unknown excite me. I like the diagnostic challenge and the pathophys/pharmacologics. Lifestyle is a huge bonus since I have a really sick kid. Loved the elective in residency and got a really good LOR (but again from someone in private practice, not some big shot researcher).

So I’m applying this cycle but I didn’t realize how competitive things are nowadays. In hindsight I should’ve looked more into it but the match rates and how many unfilled spots there are is daunting. I’ve been going to a bunch of program websites and the majority have their fellows coming from top programs a lot better than mine with publications in residency or even med school. I don’t want to become a physician scientist or anything, just a regular rheumatologist seeing patients in the office.

The second specialty I always liked is ID. At least to me there’s a similar diagnostic flow to ID and you also have to have a good understanding of IM and clinical diagnosis because sometimes the differential is broad like for those cases where the hospitalists consult onc, ID, and rheum for FUO or a super high ESR and CRP that they don’t know what to do with. Lots of cool opportunistic infections and having quick treatment responses is honestly more satisfying.

ID seems to be a lot easier getting into. Bunch of places went unmatched. Current fellows on program websites seem more like my level.

I wouldn’t hate ID if I had to do it, it’s just not my first choice because of how much I like rheumatology, having to do much more inpatient, and how overworked the docs at least in my hospital seem. Doesn’t help that ID bread and butter cases like cellulitis and diabetic foot infections are pretty boring to me while I actually enjoy dealing with even OA and gout.

I’m also wondering how the job outlook for these two specialties are. I’m supporting a family too so I have to consider finances in my decision too. I absolutely do not want to be a hospitalist or PCP or any other specialty.

I probably should have thought this through better before this application cycle beginning but just been dealing with a lot personally these last couple years.

There has been a lot of discussion regarding rheumatology on these forums. I would suggest you search for the threads.

I'm a rheumatologist and my take on it is that if you want to live in a metropolitan area or the suburbs of one, then rheumatology is not the best way to go. If you're ok living in rural (which I currently do), then rheumatology can be a solid gig. Work life balance is great, and the income potential can be quite high. You have enough autonomy with high demand for your services that allows you to select which consults you want to see.

However, if you work in a metropolitan area (which I did before my current job), then it's nothing but +ANA, joint pain, fatigue, malaise, neuropathy, unexplained symptoms, etc. Imagine your whole job is just wrestling with people who desperately want something to be wrong with them simply because they have a nonspecific lab finding. A lot would give you bad patient satisfaction scores for telling them your medical opinion. It's absolutely miserable and the income potential is simply not there to justify such a s**ty existence.

 

[TexasMed22]

There has been a lot of discussion regarding rheumatology on these forums. I would suggest you search for the threads.

I'm a rheumatologist and my take on it is that if you want to live in a metropolitan area or the suburbs of one, then rheumatology is not the best way to go. If you're ok living in rural (which I currently do), then rheumatology can be a solid gig. Work life balance is great, and the income potential can be quite high. You have enough autonomy with high demand for your services that allows you to select which consults you want to see.

However, if you work in a metropolitan area (which I did before my current job), then it's nothing but +ANA, joint pain, fatigue, malaise, neuropathy, unexplained symptoms, etc. Imagine your whole job is just wrestling with people who desperately want something to be wrong with them simply because they have a nonspecific lab finding. A lot would give you bad patient satisfaction scores for telling them your medical opinion. It's absolutely miserable and the income potential is simply not there to justify such a s**ty existence.

What are your recommendations for fellowships if one wants to live in a metro area then? The classic GI/onc/cards?

 

[bronx43]

What are your recommendations for fellowships if one wants to live in a metro area then? The classic GI/onc/cards?

I would have done onc if I can go back to residency. GI is a great option, but I suffer from terrible sleep/insomnia so I don't know that I can physically handle being on call and having to go in for emergent cases.
If that wasn't a problem, then GI hands down.

 

[dozitgetchahi]

There has been a lot of discussion regarding rheumatology on these forums. I would suggest you search for the threads.

I'm a rheumatologist and my take on it is that if you want to live in a metropolitan area or the suburbs of one, then rheumatology is not the best way to go. If you're ok living in rural (which I currently do), then rheumatology can be a solid gig. Work life balance is great, and the income potential can be quite high. You have enough autonomy with high demand for your services that allows you to select which consults you want to see.

However, if you work in a metropolitan area (which I did before my current job), then it's nothing but +ANA, joint pain, fatigue, malaise, neuropathy, unexplained symptoms, etc. Imagine your whole job is just wrestling with people who desperately want something to be wrong with them simply because they have a nonspecific lab finding. A lot would give you bad patient satisfaction scores for telling them your medical opinion. It's absolutely miserable and the income potential is simply not there to justify such a s**ty existence.

As usual, my opinion of rheumatology is less pessimistic.

I’ve had three rheumatology jobs and have had no trouble with getting adequate volumes of legit rheumatology referrals - one was in a major metro area. I have always been able to screen out nonsense and still be awash in referrals. I think this is only a problem in supersaturated huge city markets, and even then I am not sure it is as universal of an issue as he suggests it is. It is not a reason to avoid rheumatology.

I think it’s a great specialty with good income potential and one of the best work/life balances in medicine. There is a reason it is becoming as popular as it is. The people applying to it aren’t stupid.

As far as ID vs rheum: the big question is whether you like outpatient or inpatient medicine. I considered ID as well…however, I love the clinic and loathe the hospital. Thus, the choice was rheumatology.

If I could do this over, I would still have chosen rheumatology any day of the week. I made $540k at my job last year working 4.5 days a week with zero call and zero hospital rounding. Where else in medicine can you do this? Dermatology? Maybe plastics? Possibly A/I?

 

[NewYorkDoctors]

There has been a lot of discussion regarding rheumatology on these forums. I would suggest you search for the threads.

I'm a rheumatologist and my take on it is that if you want to live in a metropolitan area or the suburbs of one, then rheumatology is not the best way to go. If you're ok living in rural (which I currently do), then rheumatology can be a solid gig. Work life balance is great, and the income potential can be quite high. You have enough autonomy with high demand for your services that allows you to select which consults you want to see.

However, if you work in a metropolitan area (which I did before my current job), then it's nothing but +ANA, joint pain, fatigue, malaise, neuropathy, unexplained symptoms, etc. Imagine your whole job is just wrestling with people who desperately want something to be wrong with them simply because they have a nonspecific lab finding. A lot would give you bad patient satisfaction scores for telling them your medical opinion. It's absolutely miserable and the income potential is simply not there to justify such a s**ty existence.

Yep . This is not helped by certain PCPs who don’t bother to explain the tests they order . Ohh quest labs has an arthritis panel.
Ana 1:40 red and Lyme Ab igg positivr. Uh oh I don’t have time I explain ! That will ruin my 99213 revenue / effort ratio ! Turf to rheum ?

For my ILD patients I order a whole panel as well . Only I have enough med student knowledge to explain that the red colored result does not mean you have lupus . I’m usually able to tell a patient they don’t need Rheumatology.

Though I guess in the case of osteoarthritis patients are desperate to find that fountain of youth and it’s just a form of denial and coping that those patients turn to .

 

[bronx43]

Rheumatology isn’t as popular as people make it out to be. True that one can’t just walk into a fellowship spot but it’s well under cards, GI, onc, pulmonary and allergy.

It’s only more competitive than neph, ID, and endocrinology.

 

[dozitgetchahi]

Rheumatology isn’t as popular as people make it out to be. True that one can’t just walk into a fellowship spot but it’s well under cards, GI, onc, pulmonary and allergy.

It’s only more competitive than neph, ID, and endocrinology.

Doesn’t change anything I wrote above.

 

[bronx43]

As usual, my opinion of rheumatology is less pessimistic.

I’ve had three rheumatology jobs and have had no trouble with getting adequate volumes of legit rheumatology referrals - one was in a major metro area. I have always been able to screen out nonsense and still be awash in referrals. I think this is only a problem in supersaturated huge city markets, and even then I am not sure it is as universal of an issue as he suggests it is. It is not a reason to avoid rheumatology.

I think it’s a great specialty with good income potential and one of the best work/life balances in medicine. There is a reason it is becoming as popular as it is. The people applying to it aren’t stupid.

As far as ID vs rheum: the big question is whether you like outpatient or inpatient medicine. I considered ID as well…however, I love the clinic and loathe the hospital. Thus, the choice was rheumatology.

If I could do this over, I would still have chosen rheumatology any day of the week. I made $540k at my job last year working 4.5 days a week with zero call and zero hospital rounding. Where else in medicine can you do this? Dermatology? Maybe plastics? Possibly A/I?

I made similar income as you but let’s be transparent. We both live in rural. OP may not want to live in rural.

How far is the closest big city to you?

 

[bronx43]

Doesn’t change anything I wrote above.

You used the “competitiveness” of rheum to support why it’s a good specialty. My response is that it’s not that great of a specialty because it’s not that competitive when compared to the alternatives.

*if OP is only considering ID as other option then perhaps rheum is more attractive when using this metric

 

[dozitgetchahi]

You used the “competitiveness” of rheum to support why it’s a good specialty. My response is that it’s not that great of a specialty because it’s not that competitive when compared to the alternatives.

Seriously?

I used the good lifestyle and good income potential, and mentioned that it was becoming more popular. The vast majority of my post has nothing to do with that. Frankly I could give a **** how many other people are applying to it. (Judging specialties by how many residents are applying to them is something done a lot on SDN, but I’m not sure how much relevance it has to anything else). It would not change any of my experience with the specialty, which from a day to day practice standpoint has been quite positive.

I get that you are apparently miserable with the subspecialty of rheumatology - you’ve established this many times here on SDN. (I’m still not entirely clear why this is.) However, most rheumatologists out there that I have encountered have feelings similar to mine about it. I am providing that counterpoint because people should be aware of it.

 

[dozitgetchahi]

I made similar income as you but let’s be transparent. We both live in rural. OP may not want to live in rural.

How far is the closest big city to you?

I don’t care how close the biggest city is, because I don’t care about living in cities.

I just bought a nice house for about $200k and have a one mile commute to work. I make double what I did living in a big metropolitan area. For me, these things are worth way more than “access to a city” and sitting in hours of traffic each day. You couldn’t pay me enough to live in a major metro area at this point.

(For the record, a moderately sized big city is about 90 min away, and a huge metropolis is about 5 hours. If I have a hankering to go to a city, I do. And it’s not a big deal.)

 

[NewYorkDoctors]

I don’t care how close the biggest city is, because I don’t care about living in cities.

I just bought a nice house for about $200k and have a one mile commute to work. I make double what I did living in a big metropolitan area. For me, these things are worth way more than “access to a city” and sitting in hours of traffic each day. You couldn’t pay me enough to live in a major metro area at this point.

NYC is way overrated and I lived here for over 30 years.

SUre it was fun to go clubbing in my 20s and night life... but it's just pointless. I work in the city live in the burbs. It's not so bleak as social media makes it out to be but it is pretty *****ty compared to 20 years ago. there is just a lot of stagnation and "big opinions from lowly qualified individuals" in the city now.

 

[bronx43]

I don’t care how close the biggest city is, because I don’t care about living in cities.

I just bought a nice house for about $200k and have a one mile commute to work. I make double what I did living in a big metropolitan area. For me, these things are worth way more than “access to a city” and sitting in hours of traffic each day. You couldn’t pay me enough to live in a major metro area at this point.

(For the record, a moderately sized big city is about 90 min away, and a huge metropolis is about 5 hours. If I have a hankering to go to a city, I do. And it’s not a big deal.)

That's fine and all. I also find a decent standard of living in my current rural area.

But that wasn't the point of my question. The point is that anyone applying to rheumatology (including possibly OP) needs to know what sacrifices are required to have a decent job in rheumatology. If someone is fully happy living in a rural area, then I have said numerous times that I would recommend the field to them wholeheartedly.
For me, I rather live in a bigger city and rheumatology was not worth the geographic sacrifice. There are other specialties with limited call and inpatient exposure.

 

[bronx43]

NYC is way overrated and I lived here for over 30 years.

SUre it was fun to go clubbing in my 20s and night life... but it's just pointless. I work in the city live in the burbs. It's not so bleak as social media makes it out to be but it is pretty *****ty compared to 20 years ago. there is just a lot of stagnation and "big opinions from lowly qualified individuals" in the city now.

I would love to live in the burbs, but the problem is that true RURAL living means giving up a lot of the amenities that most people have grown accustom.

Depending on how rural a place is, we are talking about 1-2 hours from an international airport. Walmart is the biggest store in town. There isn't a Starbucks within 30 min. There are no non-chain restaurants, or decent ethnic food (Chinese buffets don't count). Even the American bistro type food is subpar. Don't even mention the breweries, gastropubs, cafes, nicely maintained parks, etc.

The vast majority of my classmates and co-residents would never move to where I live in a million years or for a million bucks.

 

[bernieout]

As usual, my opinion of rheumatology is less pessimistic.

I’ve had three rheumatology jobs and have had no trouble with getting adequate volumes of legit rheumatology referrals - one was in a major metro area. I have always been able to screen out nonsense and still be awash in referrals. I think this is only a problem in supersaturated huge city markets, and even then I am not sure it is as universal of an issue as he suggests it is. It is not a reason to avoid rheumatology.

I think it’s a great specialty with good income potential and one of the best work/life balances in medicine. There is a reason it is becoming as popular as it is. The people applying to it aren’t stupid.

As far as ID vs rheum: the big question is whether you like outpatient or inpatient medicine. I considered ID as well…however, I love the clinic and loathe the hospital. Thus, the choice was rheumatology.

If I could do this over, I would still have chosen rheumatology any day of the week. I made $540k at my job last year working 4.5 days a week with zero call and zero hospital rounding. Where else in medicine can you do this? Dermatology? Maybe plastics? Possibly A/I?

I definitely would see myself better as a rheumatologist and like outpatient much more than inpatient. I hate inpatient as a resident but doing my ID rotation in the hospital wasn’t as bad.

I appreciate the discussion between you and Bronx regarding the job market in bigger cities vs a rural environment. Personally I don’t prefer living in a big city. I grew up in a small rural town and would much rather prefer living in a small town or rural setting in the South or Midwest than a big city on the coasts.

The major thing I’m worried about then is if I’m competitive for a rheumatology spot and if not should I even bother applying? ID is much easier to get into it seems and it’s something I could tolerate doing unlike being a PCP or hospitalist or another fellowship. I would hate doing those especially being a hospitalist.

And then if I should really consider ID instead how is that job market?

 

[dozitgetchahi]

I definitely would see myself better as a rheumatologist and like outpatient much more than inpatient. I hate inpatient as a resident but doing my ID rotation in the hospital wasn’t as bad.

I appreciate the discussion between you and Bronx regarding the job market in bigger cities vs a rural environment. Personally I don’t prefer living in a big city. I grew up in a small rural town and would much rather prefer living in a small town or rural setting in the South or Midwest than a big city on the coasts.

The major thing I’m worried about then is if I’m competitive for a rheumatology spot and if not should I even bother applying? ID is much easier to get into it seems and it’s something I could tolerate doing unlike being a PCP or hospitalist or another fellowship. I would hate doing those especially being a hospitalist.

And then if I should really consider ID instead how is that job market?

As alluded to above, rheumatology is somewhat more competitive than it was before…but not extremely so. I don’t think it’s all that hard to match rheumatology at this point, even compared to the past. It’s probably harder than ID (who will take practically anyone at this point), but if you apply broadly, have good recommendation letters, and maybe have a touch of research your chances should be reasonably good.

I matched to a good program in 2016 with two good letters and no real rheum specific research (I had a med school poster on a case where infliximab failed to resolve pyoderma gangrenosum). I was an above average resident who switched to rheum from Heme/onc at the last minute. It all worked out.

 

[sloh]

I would love to live in the burbs, but the problem is that true RURAL living means giving up a lot of the amenities that most people have grown accustom.

Depending on how rural a place is, we are talking about 1-2 hours from an international airport. Walmart is the biggest store in town. There isn't a Starbucks within 30 min. There are no non-chain restaurants, or decent ethnic food (Chinese buffets don't count). Even the American bistro type food is subpar. Don't even mention the breweries, gastropubs, cafes, nicely maintained parks, etc.

The vast majority of my classmates and co-residents would never move to where I live in a million years or for a million bucks.

Do you feel really out of place when you go to Walmart (if you go)? That’s my hesitation about rural living. I’d feel like an outcast.

 

[dozitgetchahi]

Do you feel really out of place when you go to Walmart (if you go)? That’s my hesitation about rural living. I’d feel like an outcast.

I live in a town of about 40k.

There are chains galore, and two Starbucks within 5 min of my house. There are nicely maintained parks, a Target, a Walmart. Some local restaurants are very good (there is an upscale Italian place that is among the best Italian restaurants I’ve ever eaten at, even well-regarded ones in big cities). There are well maintained hiking trails. Do I miss the full diversity of ethnic foods? Yes, and that’s about the only thing I miss living here Vs a major metro area. But my wife and I have learned to cook a lot of that ourselves, and we can go to the big city to get our fix if we want to. Neither of us feels that it’s worth paying 4-5x more for a house (while making about 50% less) to get more of that.

My quality of life is the best it’s ever been in the semi rural Midwest right now. Making $500k plus a year is a big part of that. I would never trade what I have now for the crappy pay, crappy hospital admin, super high cost of living, sitting in traffic for hours a day, etc BS that I dealt with living in a metro area. It is just not worth it to me, and I think if a lot of docs gave it a chance, a lot of them would see that it isn’t worth it to them either. Most docs that work at my practice feel like this is a “unicorn job”, a sort of “best kept secret” that they wish they had happened upon earlier in their careers.

(PS: Even when I lived in “rural” Alabama, most of these things were there too.)

 

[eyeeye_captain]

Do you feel really out of place when you go to Walmart (if you go)? That’s my hesitation about rural living. I’d feel like an outcast.

If you ever go to a Walmart at 2 AM, you'll quickly realize that anything goes

 

[Renal_Prometheus]

I just bought a nice house for about $200k

Wow!!! Must be really rural

 

[Renal_Prometheus]

It’s probably harder than ID (who will take practically anyone at this point)

I can think of another specialty that is equally non-selective.

 

[bronx43]

Do you feel really out of place when you go to Walmart (if you go)? That’s my hesitation about rural living. I’d feel like an outcast.

Like dozitgetchahi, I also live in a city/town about 40-50k. That's quite a common size in the Midwest, since they are basically the remnants of old industrial towns where the industry didn't completely die. However, they also don't get very big given the lack of new industry and the distance to a major metropolitan area.

There are quite a few other grocery options outside Walmart in my city and the chain establishments are well entrenched here. However, this isn't a very diverse place and I'm not caucasian. So, I do kind of stick out and I can see how one can feel out of place.

There are several other job postings in my state, where it's true rural... the population density is a lot lower, and Walmart is literally the biggest store within 20 miles. Even chain restaurants start to be few and far between when you get that far from the cities. I would find it much harder to live in that kind of environment, but YMMV?

 

[Prehealth1011]

A classmate of mine went into Rheum this year because they're gunning for that infusion moneyy.

 

[NewYorkDoctors]

Like dozitgetchahi, I also live in a city/town about 40-50k. That's quite a common size in the Midwest, since they are basically the remnants of old industrial towns where the industry didn't completely die. However, they also don't get very big given the lack of new industry and the distance to a major metropolitan area.

There are quite a few other grocery options outside Walmart in my city and the chain establishments are well entrenched here. However, this isn't a very diverse place and I'm not caucasian. So, I do kind of stick out and I can see how one can feel out of place.

There are several other job postings in my state, where it's true rural... the population density is a lot lower, and Walmart is literally the biggest store within 20 miles. Even chain restaurants start to be few and far between when you get that far from the cities. I would find it much harder to live in that kind of environment, but YMMV?

nice.

honestly if I were Caucasian I would totally move out to the sticks. I have no desire to do anything other than work, spend time with the kids, and be on my computers (for work and non-work reasons). yes that was a pleural.

but as a non-Caucasian I find more business opportunities in NYC. Anyway I spend all of my time on either at work or on my computers so I'm not really living as a "New yorker urbanite gothamite" anymore.

in the NY greater metro area, a "nice house" 5 bedroom runs at least 2.5 million now

 

[bronx43]

A classmate of mine went into Rheum this year because they're gunning for that infusion moneyy.

Gunning for rheum infusion money now is like going to the buffet 5 min before closing time. Sure, there are prob still a few edible pieces of chicken but you’re prob better off elsewhere.

 

[NewYorkDoctors]

besides rituximab and IV CYC, are there any frequent IV infusions used first line anymore for any of the rheum conditions?

I mean I manage a few lupus nephritis patients. Although i start with MMF, I do send some people to the local NY Blood and Cancer infusion center for CYC. hematology consults on those patients just to get a cool 99204/5 then help collect some infusion fees and send these patients back to me with side effects lol.

isn't it most SC injection agents these days for most conditions?

 

[MD46]

Gunning for rheum infusion money now is like going to the buffet 5 min before closing time. Sure, there are prob still a few edible pieces of chicken but you’re prob better off elsewhere.

Quite a few Rheum, GI, A/I and Neurology etc just use Heme Onc infusion units for their infusions.

They write all orders and adjust accordingly however in private we would do a quick office visit. Bill level 4 and also get infusion revenue. For some of these infusion, you usually just break even.

 

[sloh]

However, this isn't a very diverse place and I'm not caucasian. So, I do kind of stick out and I can see how one can feel out of place.

Did my training in Michigan and I totally get what you mean. I’m also not Caucasian

 

[bronx43]

besides rituximab and IV CYC, are there any frequent IV infusions used first line anymore for any of the rheum conditions?

I mean I manage a few lupus nephritis patients. Although i start with MMF, I do send some people to the local NY Blood and Cancer infusion center for CYC. hematology consults on those patients just to get a cool 99204/5 then help collect some infusion fees and send these patients back to me with side effects lol.

isn't it most SC injection agents these days for most conditions?

Most of the biologics are for RA, psoriatic arthritis/psoriasis, ankylosing spondylitis - the TNF alpha inhibitors, IL-6 inhibitor, co-stim blockers.

Rituximab is relatively common too since we use it for RA as well as lupus/vasculitis.

The problem is that the margin on most of these (with exception of Cimzia and Orencia) is so low that the risk of buying/billing isn't even worth it for a lot of rheum offices. This is probably why more heme onc infusion sites are being utilized.

 

[Renal_Prometheus]

Most of the biologics are for RA, psoriatic arthritis/psoriasis, ankylosing spondylitis - the TNF alpha inhibitors, IL-6 inhibitor, co-stim blockers.

Rituximab is relatively common too since we use it for RA as well as lupus/vasculitis.

The problem is that the margin on most of these (with exception of Cimzia and Orencia) is so low that the risk of buying/billing isn't even worth it for a lot of rheum offices. This is probably why more heme onc infusion sites are being utilized.

It’s kind of crazy that heme/onc has managed to maintain their margins all these years on chemo infusions. The specialty would be just like nephrology if money goes away. I wonder why CMS get to play favorites and destroy certain specialties and uphold others. Good lobbyists?

 

[dozitgetchahi]

Most of the biologics are for RA, psoriatic arthritis/psoriasis, ankylosing spondylitis - the TNF alpha inhibitors, IL-6 inhibitor, co-stim blockers.

Rituximab is relatively common too since we use it for RA as well as lupus/vasculitis.

The problem is that the margin on most of these (with exception of Cimzia and Orencia) is so low that the risk of buying/billing isn't even worth it for a lot of rheum offices. This is probably why more heme onc infusion sites are being utilized.

Infusion margins heavily depend on your location, your volumes, and the business acumen of who runs the place.

Our infusion center is highly profitable, and we have good margins on everything except for biosimilars of Rituxan (Truxima, etc) and Remicade. Again, your experience is not universal.

 

[NewYorkDoctors]

It’s kind of crazy that heme/onc has managed to maintain their margins all these years on chemo infusions. The specialty would be just like nephrology if money goes away. I wonder why CMS get to play favorites and destroy certain specialties and uphold others. Good lobbyists?

If the lobbyists did not support the cardiologists so hard, then cardiac caths would go to interventional radiology so fast...

also a similar thing I noticed about lung cancer and ESRD. there are no "Susan B Komen" foundations or pink ribbons for lung cancer or ESRD.... not a racial thing but just a socioeconomic thing I surmise. If rich well off people can get affected by it, you betcha those diseases are getting more attention, lobbying, and funding.

 

[dozitgetchahi]

It’s kind of crazy that heme/onc has managed to maintain their margins all these years on chemo infusions. The specialty would be just like nephrology if money goes away. I wonder why CMS get to play favorites and destroy certain specialties and uphold others. Good lobbyists?

I think this largely comes down to volume. You get larger discounts for larger volumes of drug purchased when you buy/bill. The average Heme/onc practice infuses a ****load of chemo compared to the average rheumatology practice. Thus, bigger volumes => bigger discounts => more profit.

As I said above, however, it is absolutely possible to turn a profit on infused biologics. We do so quite handsomely.

 

[bronx43]

Infusion margins heavily depend on your location, your volumes, and the business acumen of who runs the place.

Our infusion center is highly profitable, and we have good margins on everything except for biosimilars of Rituxan (Truxima, etc) and Remicade. Again, your experience is not universal.

I never claimed it can’t be profitable- simply that it’s most likely closer to the end of the gravy train than the beginning for a variety of reasons.

It’s really only a few drugs: infliximab, abatacept, rituximab, golimumab, certolizumab and tocilizumab. I guess secukinumab just became lyophilized so I don't know the pricing/margins. Ultimately, we aren’t oncologists with a catalog full of high priced infusion drugs.

I assume you don’t want to divulge your infusion centers books, but I would bet money that any profitable center is being carried by Cimzia and Orencia. The base profit margin for tocilizumab and golimumab last time I checked simply wasn't anything to write home about.
Sure, more volume means slightly bigger discounts, but unless it's 340b pricing, the majority of the profit will still come from the big 2 for rheum. If those 2 went down, then it's basically nail in the coffin for most suites.

 

[TexasMed22]

It’s kind of crazy that heme/onc has managed to maintain their margins all these years on chemo infusions. The specialty would be just like nephrology if money goes away. I wonder why CMS get to play favorites and destroy certain specialties and uphold others. Good lobbyists?

I'm not an expert on this, but I think CMS recently tried to change their 6% commissions on infusions to like 2% or something, and then it was reversed by the supreme court for some reason. So it at least sounds like they are trying to go after it. If that went through I would guess it would be devastating for onc reimbursement.

Supreme Court Unanimously Rules in Favor of Hospitals in 340B Decision

The Supreme Court has ruled that HHS' decision to lower reimbursement rates to hospitals so that those in the 340B program received reduced rates because they received discounted drugs was unlawful.

www.ajmc.com

CMS' 340B Repayment Proposal May Harm Vulnerable Hospitals, Reward Those With Higher Revenues

The 340B hospitals not receiving an offsetting lump-sum payment from CMS following 2018-2022 cuts later ruled unlawful are disproportionately rural, publicly owned, and nonacademic, according to a new study.

www.ajmc.com

 

[bernieout]

Thank you guys for the insight into the rheum job market nowadays. Like I said I’m not someone who is drawn to urban/metro environments so if I end up practicing in a rural place in WV or IA I’d honestly be happy.

I’m also not unrealistic in my expectations of how much I’ll make as a rheumatologist. I know some rheumatologists make bank doing infusions but I understand that probably won’t be me unless I find a really good gig. Long term I’m honestly just looking for a nice place to raise my kid and live a good comfortable life.

I’m guessing based on my “stats” I’m probably on the lower tier of applicants but I guess I should still give it a try.

I’d be interested if anyone has any insights into ID in terms of job market and lifestyle.

The other question I have I guess is if I do end up going all in with applying to rheumatology fellowships and don’t find a spot, what’s the process and how hard will it be to find an ID spot instead? Like I said ID is something I could see myself doing but not as happily as rheumatology. And I would much rather do ID than anything else.

I can think of another specialty that is equally non-selective.

Don’t worry. I’m never considering nephrology.

 

[Prehealth1011]

The other question I have I guess is if I do end up going all in with applying to rheumatology fellowships and don’t find a spot, what’s the process and how hard will it be to find an ID spot instead? Like I said ID is something I could see myself doing but not as happily as rheumatology. And I would much rather do ID than anything else.

As soon as you go unmatched, you’ll get emails from unfilled ID programs.

 

[Legend of Link]

That's fine and all. I also find a decent standard of living in my current rural area.

But that wasn't the point of my question. The point is that anyone applying to rheumatology (including possibly OP) needs to know what sacrifices are required to have a decent job in rheumatology. If someone is fully happy living in a rural area, then I have said numerous times that I would recommend the field to them wholeheartedly.
For me, I rather live in a bigger city and rheumatology was not worth the geographic sacrifice. There are other specialties with limited call and inpatient exposure.

What other speciality would you recommend then that has a decent pay with limited call and inpatient exposure?
Last I checked the heme onc guys at our hospital takes quiet a lot calls (plus inbox burden and never be able to be "off") and has frequent inpatient rounds. One reason I kind of moved away from heme onc cause I absolutely do not enjoy the hassle of inpatient medicine.

 

[Prehealth1011]

What other speciality would you recommend then that has a decent pay with limited call and inpatient exposure?

This depends on what you consider to be decent pay. You can probably get an academic onc job, have fellows taking call and make similar to what a typical rheum would make.

 

[TexasMed22]

This depends on what you consider to be decent pay. You can probably get an academic onc job, have fellows taking call and make similar to what a typical rheum would make.

Academic onc gets paid like a hospitalist (actually less in my area). Avoid

 

[bronx43]

What other speciality would you recommend then that has a decent pay with limited call and inpatient exposure?
Last I checked the heme onc guys at our hospital takes quiet a lot calls (plus inbox burden and never be able to be "off") and has frequent inpatient rounds. One reason I kind of moved away from heme onc cause I absolutely do not enjoy the hassle of inpatient medicine.

I mean, if one needs zero inpatient at all then rural rheum/endo or allergy would be only options. When I was working in a metro area, I still had inpatient duties.

Inbox burden is largely job dependent. My inbox burden in the city was truly horrific - just literally bombarded daily with complaints of random symptoms and people complaining that you don’t take their symptoms seriously. Every few days I would get a message that was about 2 pages of stream of consciousness from a chronic fatigue/pain patient.

Inpatient service was much much more tolerable in contrast…

 

[bronx43]

Academic onc gets paid like a hospitalist (actually less in my area). Avoid

My friend is an academic oncologist in the city and her pay is same base salary as a hospitalist but she literally does only 2-3 half days of clinic a week and does “research” or teaching with her other time. She does have inpatient service once every few months.
Contrast this to my city job where I was doing 8 half days of clinic plus inpatient service once every 2 months for $60k less.

 

[MD46]

From where I graduated- fellowship-HO (mid tier university program) this was almost 6 yrs ago, base salary for an instructor was around 220-230k

4 half clinic days only (always one fellow and one NP in clinic) , inpatient service coverage was once every 8 weeks or so for 1 week at a time .

Not very busy as 2-3 fellows were on along with quite a few residents and Sub-Is etc.

 

[hotsaws]

The choice between ID and rheum is strange to me. They are quite different. I totally see the appeal to rheum -- outpt, normal hours, income potential is solid for the work put in, etc. If worried about competitiveness of rheum, endo would seem like a nice alternative. A/I fits nicely but is probably more competitive or certainly not any easier to get in to.

But ID is very different. Inpt heavy, typically. I don't see much in terms of outpt ID around here although there is at least one large practice that I can think of. Income is not known to be high. I'm sure there are some people out there who grind out pt encounters but I think you're largely dependent on E/M visits or inpt consults to drive revenue and not really any ancillary services or passive income. I imagine you can make more as a hospitalist, have way more geographic options and transportability, and save yourself two years of lost income as a fellow. So, you would have to really love ID as a specialty (or maybe just dread general IM so much ...) in order to choose it. If you're cool with more rural practice settings, you can do well as a hospitalist or outpt IM and probably find lucrative work quite readily. My guess is if you went into ID and wanted to live rural or semi rural, you'd be putting in part time hospitalist work anyways. I have heard of ID starting to monetize telehealth more and more since there is a role for just algorithmically managing long term therapies based on culture/biopsy/whatever results.

Funny that you think of ID as a highly cognitive, interesting specialty. In my residency, I didn't get that impression. Not trying to be a hater but it seemed like they just used a smart phrase to order a ton of random labs (sputums, blood, csf, bla bla bla). The workups took forever, delayed care, resulted in all kinds of empiric therapy until the esoteric results excluding some diagnosis finally came back. I rarely felt like they were a big help. The main service ID provided IMO was we could sort of dispo the osteo/endocarditis/fungal whatever infection and they would take care of long term follow up with setting up drug therapy and lab monitoring. I just imagine some poor inbox full of CBC/CMP/ESR/CRPs/repeat cultures/etc. in an often frustrating and chronically ill patient base. You know who showed up with nasty, chronic, resistant infections in my experience? IV drug users, homeless people, obese non compliant diabetics, and really old or chronically ill people. I wasn't seeing alot of like "oh this is super interesting rare disease from my med school text books." It was more like "oh its you again...well we are cutting off more of your leg" or "oh its you again...you shot dope with a dirty needle into the port we were using to treat your endocarditis" or "oh its you again, with the non compliant CF and a personality disorder who is resistant to every antibiotic except some stuff we keep in the basement under lock and key."

 

[NewYorkDoctors]

The choice between ID and rheum is strange to me. They are quite different. I totally see the appeal to rheum -- outpt, normal hours, income potential is solid for the work put in, etc. If worried about competitiveness of rheum, endo would seem like a nice alternative. A/I fits nicely but is probably more competitive or certainly not any easier to get in to.

But ID is very different. Inpt heavy, typically. I don't see much in terms of outpt ID around here although there is at least one large practice that I can think of. Income is not known to be high. I'm sure there are some people out there who grind out pt encounters but I think you're largely dependent on E/M visits or inpt consults to drive revenue and not really any ancillary services or passive income. I imagine you can make more as a hospitalist, have way more geographic options and transportability, and save yourself two years of lost income as a fellow. So, you would have to really love ID as a specialty (or maybe just dread general IM so much ...) in order to choose it. If you're cool with more rural practice settings, you can do well as a hospitalist or outpt IM and probably find lucrative work quite readily. My guess is if you went into ID and wanted to live rural or semi rural, you'd be putting in part time hospitalist work anyways. I have heard of ID starting to monetize telehealth more and more since there is a role for just algorithmically managing long term therapies based on culture/biopsy/whatever results.

Funny that you think of ID as a highly cognitive, interesting specialty. In my residency, I didn't get that impression. Not trying to be a hater but it seemed like they just used a smart phrase to order a ton of random labs (sputums, blood, csf, bla bla bla). The workups took forever, delayed care, resulted in all kinds of empiric therapy until the esoteric results excluding some diagnosis finally came back. I rarely felt like they were a big help. The main service ID provided IMO was we could sort of dispo the osteo/endocarditis/fungal whatever infection and they would take care of long term follow up with setting up drug therapy and lab monitoring. I just imagine some poor inbox full of CBC/CMP/ESR/CRPs/repeat cultures/etc. in an often frustrating and chronically ill patient base. You know who showed up with nasty, chronic, resistant infections in my experience? IV drug users, homeless people, obese non compliant diabetics, and really old or chronically ill people. I wasn't seeing alot of like "oh this is super interesting rare disease from my med school text books." It was more like "oh its you again...well we are cutting off more of your leg" or "oh its you again...you shot dope with a dirty needle into the port we were using to treat your endocarditis" or "oh its you again, with the non compliant CF and a personality disorder who is resistant to every antibiotic except some stuff we keep in the basement under lock and key."

agreed totally

Inpatient ID is a very vital service... but that is not because of the Chaga's diseases, Ebola, Crimnea-Congo Hemorrhagic fever, African Sleeping Sicknesses of the world... or even the HIV and opportunistic infections but because of maging common infections that are the long term result of obesity and metabolic syndrome. woe.

There are a few private practice ID docs near me but they usually see their hospital followups or see things like chronic / recurrent UTI and help manage latent

There is academic ID I refer to but usually when second line antibiotics are needed for pulmonary infections

For bronchiectasis (non-CF usually as those patients are in the children's hospitals are academic centers of excellence) , NTM patients, and fungal lung disease, I usually don't bother with ID because I need to get the sputum, possibly the bronch, start pulmonary hygiene, or start empiric therapy myself anyway, While inpatient, I will need ID on board for the "big guns" as ID approval is required in the hospital. but outpatient I usually just manage these infections myself and get the appropriate antimicrobials myself as it is just faster to do so myself.

 

[AlbinoHawk DO]

I’m a US IMG applying for fellowship this cycle. I have decent step scores (~230s), some case report posters mostly rheum but a few ID/rheum overlap, and am at a community program where the closest rheumatology exposure that we rotate with is a private practice clinic about an hour away. My residency has no research opportunities and very few QI anything and has not been support with me do anything in that realm or even going to conferences out of state or away rotations.

I have always really liked rheumatology since med school. The diseases and the unknown excite me. I like the diagnostic challenge and the pathophys/pharmacologics. Lifestyle is a huge bonus since I have a really sick kid. Loved the elective in residency and got a really good LOR (but again from someone in private practice, not some big shot researcher).

So I’m applying this cycle but I didn’t realize how competitive things are nowadays. In hindsight I should’ve looked more into it but the match rates and how many unfilled spots there are is daunting. I’ve been going to a bunch of program websites and the majority have their fellows coming from top programs a lot better than mine with publications in residency or even med school. I don’t want to become a physician scientist or anything, just a regular rheumatologist seeing patients in the office.

The second specialty I always liked is ID. At least to me there’s a similar diagnostic flow to ID and you also have to have a good understanding of IM and clinical diagnosis because sometimes the differential is broad like for those cases where the hospitalists consult onc, ID, and rheum for FUO or a super high ESR and CRP that they don’t know what to do with. Lots of cool opportunistic infections and having quick treatment responses is honestly more satisfying.

ID seems to be a lot easier getting into. Bunch of places went unmatched. Current fellows on program websites seem more like my level.

I wouldn’t hate ID if I had to do it, it’s just not my first choice because of how much I like rheumatology, having to do much more inpatient, and how overworked the docs at least in my hospital seem. Doesn’t help that ID bread and butter cases like cellulitis and diabetic foot infections are pretty boring to me while I actually enjoy dealing with even OA and gout.

I’m also wondering how the job outlook for these two specialties are. I’m supporting a family too so I have to consider finances in my decision too. I absolutely do not want to be a hospitalist or PCP or any other specialty.

I probably should have thought this through better before this application cycle beginning but just been dealing with a lot personally these last couple years.

Don't waste your time with ID since you'll just end up making less money in the end. The only way ID makes sense is if you know you want to move to some area where's nobody else doing ID and are okay getting paid the same as a hospitalist. This is okay when you genuinely like and want to be an ID doctor, but if it's just second best, you'll probably drop out of fellowship since it's worse than being in residency

 

[dozitgetchahi]

What other speciality would you recommend then that has a decent pay with limited call and inpatient exposure?
Last I checked the heme onc guys at our hospital takes quiet a lot calls (plus inbox burden and never be able to be "off") and has frequent inpatient rounds. One reason I kind of moved away from heme onc cause I absolutely do not enjoy the hassle of inpatient medicine.

Rheumatology.

I lived in an urban area as a rheumatologist and did not experience what he is talking about with being inundated with fibromyalgia and “functional issues” etc.

You need to understand that his opinion about rheumatology is something of an outlier. Most rheumatologists out there do not share his perspective on the specialty. Most of us really like our jobs.

 

[bronx43]

Rheumatology.

I lived in an urban area as a rheumatologist and did not experience what he is talking about with being inundated with fibromyalgia and “functional issues” etc.

You need to understand that his opinion about rheumatology is something of an outlier. Most rheumatologists out there do not share his perspective on the specialty. Most of us really like our jobs.

Have any proof? Or just your anecdotal evidence.

I know quite a few rheumatologists who at best tolerate the field due to the lifestyle but have major issues with it - like I do. Do a lot like it? Sure, but that's true for all fields.

There have been numerous surveys showing low fulfillment and higher than expected burnout rates for rheumatology (compared to oncology).

 

[mono no aware]

Funny that you think of ID as a highly cognitive, interesting specialty. In my residency, I didn't get that impression. Not trying to be a hater but it seemed like they just used a smart phrase to order a ton of random labs (sputums, blood, csf, bla bla bla). The workups took forever, delayed care, resulted in all kinds of empiric therapy until the esoteric results excluding some diagnosis finally came back. I rarely felt like they were a big help. The main service ID provided IMO was we could sort of dispo the osteo/endocarditis/fungal whatever infection and they would take care of long term follow up with setting up drug therapy and lab monitoring. I just imagine some poor inbox full of CBC/CMP/ESR/CRPs/repeat cultures/etc. in an often frustrating and chronically ill patient base. You know who showed up with nasty, chronic, resistant infections in my experience? IV drug users, homeless people, obese non compliant diabetics, and really old or chronically ill people. I wasn't seeing alot of like "oh this is super interesting rare disease from my med school text books." It was more like "oh its you again...well we are cutting off more of your leg" or "oh its you again...you shot dope with a dirty needle into the port we were using to treat your endocarditis" or "oh its you again, with the non compliant CF and a personality disorder who is resistant to every antibiotic except some stuff we keep in the basement under lock and key."

Then to be frank that's because you're ignorant about what we do and not because we literally just sit around and order a bunch of random labs. I can't remember the last time I recommended both sputum and CSF cultures on the same patient -- and in what world are ID doctors leading to more empiric antimicrobial therapy and not less?

Maybe you just worked with crappy ID doctors (I'm not ruling that possibility out) but the majority of my consults start with some poorly formed question like "fevers" or "bacteremia" or "leukocytosis" or "antibiotic recommendations" and by the time I've seen them that day they actually for the first time have been given a diagnosis or at least a much more precise identification of their syndrome that directs what tests what we need to do to get a diagnosis -- and even when there is already a diagnosis, it's often wrong or there's some aspect of it that no one has appreciated or defined that is going to dictate what treatment is right for the patient, which all never would've happened if no one had put in an ID consult. This is my reality as a practicing community ID doctor and if the people consulting me had the opinion you have of ID doctors that would piss me off and it could only mean they're just too poor of clinicians to understand the service I'm providing.

No one's forcing all these ID consults to be obtained anyway (I suppose there are a few exceptions from antimicrobial stewardship programs) and if people thought we were unhelpful and only delayed care our lists wouldn't be as long as they are.

A lot of illness that puts people in the hospital or a clinic is ultimately the downstream effect of psychosocial ills or poor lifestyle choices and ID is not even close to being unique in that regard. And being consultants transiently involved in the patient's acute, curable problem, we don't come to own the unpalatable aspects in the way a lot of other fields have to.

While a lot of our consult volume isn't the exotic and rare infections people tend to think of when they romanticize the field of ID, you guys are underestimating the amount of rarer and unusual stuff that we do tend to see. Just going back the past few months, a list of things I've seen/diagnosed/treated includes brucellosis, Aeromonas hydrophila cellulitis after river water exposure, Mollaret's meningitis, Q fever, cat scratch disease, early disseminated Lyme disease x2 one presenting as bilateral facial nerve palsy, paratyphoid fever in a returning traveler, Mycobacterium marinum finger infection, pneumocystis pneumonia, subacute progressive disseminated histoplasmosis, and pulmonary blastomycosis.

But it's often the cases within the more routine, where I don't have to bust out all the inquiry into where a patient's a been and what they've done to get that exposure history that ID is famous for, that end up being the most rewarding. Like being the first person to suspect that the fever is from a hardware-associated osteomyelitis, or the "E coli bacteremia from UTI" is actually cholangitis from an obstructing gallstone and they're going to need ERCP, or figuring the patient with bacteremia and AV block needs a TEE to find the endocarditis and aortic root abscess, or the early recognition that the patient just admitted to the ICU with septic shock should get meropenem rather than cefepime because they've seen just a little too much beta-lactam lately and they're already well on their way to recovery by the time the blood cultures pop positive for ESBL(+) Klebsiella pneumoniae.

Those are the kinds of things we deal with day in and day out, and almost every consult we get is a bit of a puzzle that it takes some one with specialized ID knowledge to put together. I rarely go a few days without thinking, huh this is really interesting. Most people consider ID to be a cognitive field and I'm sure if you polled doctors on who the best diagnosticians in the hospital are we'd be near if not at the top of the list. I love my job and would choose ID again without hesitation. On good days it can legitimately feel like I'm doing a hobby.

ID has some real cons (the compensation problem being the main one), but not being interesting, not being cognitive, and not being helpful I have to say based on my experience as an ID doctor are definitely not among them.

--

To the OP, ID and Rheum were the two fields at the top of my list in the preclinical and early clinical years. I knew I loved microbiology and immunology and that I generally fell on the cognitive, non-procedural side of things, was most fascinated by cases where there's a diagnostic mystery, and didn't want to be restricted to a single organ system. In a lot of ways I think rheumatologists and ID doctors are cut from the same cloth, but in a few very meaningful ways we are actually exact opposites. Rheumatologists prefer to be in clinic; ID doctors, in the hospital. Rheumatologists want to be doing chronic disease management; ID doctors, dealing with acute, fixable problems. Rheumatologists are comfortable with a bit mystery in their diagnoses; ID doctors tend to be a little compulsive about having the culture result or diagnostic test that can point out an exact cause.

I could read about rheumatologic diseases and keep myself very interested, but if I had to spend all my time in the clinic and have my bread and butter be titrating immunosuppressive drugs for RA, I would be bored to tears. And that's even before considering the huge amount of somatoform disorders rheumatologists unfortunately get stuck seeing; a decent proportion of my new outpatient referrals even in ID end up being this so I can't imagine the pain of the average community rheumatologist. The most interesting part of rheumatology for me -- the FUO or the multisystem inflammatory illness of unknown etiology type consults -- ends up being the slice of rheumatology that I see as an ID doctor anyway. And since it can be hard to get a rheumatologist to see a patient in the hospital, it's often on us to consider and sometimes even make a rheumatologic diagnosis. I made a diagnosis of adult-onset Still's not too long ago and recently referred a patient to rheumatology who had proximal muscle weakness and skin findings which I suspect might be dermatomyositis.

It can be hard to know which of the two you prefer before you actually do them. Preconceived notions about what a field is like often end up being wrong. What most tells me that you might prefer being a rheumatologist to an ID doctor though is this sentence:

Doesn’t help that ID bread and butter cases like cellulitis and diabetic foot infections are pretty boring to me while I actually enjoy dealing with even OA and gout.