verok1943

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May 23, 2016
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Hi SDN,

I was just curious whether rheumatologists pursuing sports medicine fellowship and practicing both rheumatology and sports medicine is a career path that is commonly undertaken. I enjoy studing rheumatologic pathologies, but I also enjoyed the non-surgical aspects of my orthopedic surgery rotation as well. Is practicing both Rheum and Sports Med feasible? Are they complimentary fields? Would there be too much of a fight with Ortho docs for patients? I don't suppose that employers (if ever) look for a physician that's double boarded in Rheum and Sports Med. Also, the extra year of sports med fellowship on top of rheumatology (which already doesn't give much higher salary than IM) probably wouldn't increase earning potential very much if at all

Many thanks for your thoughts
 

Crayola227

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this doesn't make a lot of sense to me, really in any way

straight up Sport Med sounds like your thing or
PM&R sounds more like the blend you're looking for
 
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verok1943

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this doesn't make a lot of sense to me, really in any way

straight up Sport Med sounds like your thing or
PM&R sounds more like the blend you're looking for
Thanks for the reply!

I've shadowed a PMR guy for a little while and I found it rather dry. Also, he told me straight up that if I like being a "sherlock holmes" (which I do hence interest in IM), then PM&R is not the field for me because what physiatrists deal with is very black and white. I was looking into rheumatology and sports medicine to see if one can be an all-encompassing musculoskeletal/joint expert that diagnoses and treats these conditions non-operatively. Judging by your response though, it doesn't sound like a career path that a rheumatologist chooses to pursue
 

gutonc

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Thanks for the reply!

I've shadowed a PMR guy for a little while and I found it rather dry. Also, he told me straight up that if I like being a "sherlock holmes" (which I do hence interest in IM), then PM&R is not the field for me because what physiatrists deal with is very black and white. I was looking into rheumatology and sports medicine to see if one can be an all-encompassing musculoskeletal/joint expert that diagnoses and treats these conditions non-operatively. Judging by your response though, it doesn't sound like a career path that a rheumatologist chooses to pursue
If that's what you want to do, FM-->Sports is a better (and much more trodden) path.
 

drfunktacular

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Agree with previous posters. Rheumatology and sports medicine are not commonly combined (or ever, as far as I am aware). Sports medicine is more commonly pursued by non-orthopedists out of Family Medicine but even then many of them end up working in an ortho practice. I'm sure my perspective is skewed but for the most part sports medicine seems to me to be a referral pathway of young, healthy, insured patients to orthopedic surgeons.

In the real world, rheumatologists do a lot of non-operative management of musculoskeletal diseases such as osteoarthritis, tendonitis, bursitis, etc. I do lots of steroid injections, bracing, splinting, PT referrals--more than I would like to, in fact :whistle:. Many patients get referred to a rheumatologist for "arthritis" who just have rotator cuff disease, knee OA, trochanteric bursitis, etc so we end up managing a lot of those things without ever involving an orthopedic surgeon.Honestly that is the boring part of rheumatology.

I'm not sure what you mean by managing all of these musculoskeletal disorders "non-operatively".... most musculoskeletal disorders are (or should be) managed non-operatively. Until they shouldn't (or can't) in which case they should have surgery. Tennis elbow shouldn't ordinarily be managed operatively, nor should mild knee OA. On the other hand, an acute full-thickness rotator cuff tear or end-stage OA with malalignment should be treated surgically. There's a spectrum, and the more important part of musculoskeletal care is routing people to the appropriate modality for their problem.

I agree with the assessment that PMR is pretty cut-and-dry. There is not much in the way of diagnostic dilemma in most cases--by the time someone makes it to PMR they have already had a stroke, spinal cord injury, major ortho surgery, etc and just need an appropriate rehab plan to be put in place and monitored.
 

Crayola227

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Thanks for the reply!

I've shadowed a PMR guy for a little while and I found it rather dry. Also, he told me straight up that if I like being a "sherlock holmes" (which I do hence interest in IM), then PM&R is not the field for me because what physiatrists deal with is very black and white. I was looking into rheumatology and sports medicine to see if one can be an all-encompassing musculoskeletal/joint expert that diagnoses and treats these conditions non-operatively. Judging by your response though, it doesn't sound like a career path that a rheumatologist chooses to pursue
The reason I tell you this is because what rheumatologists deal goes way beyond just treating painful joints. They are responsible for almost ALL the autoimmune diseases and immunosuppresssion. Mainly processes that are directed directly at connective tissue, vasculature, other parts of the joint organ, or some other systemic process that has joint inflammation as a symptom. Ankylosing spondylitis, scleroderma, lupus, polymyalgia rheumatica, vasculitis, etc. Rheumatoid arthritis causing shoulder damage is a way different beast than someone who has injured their shoulder snowboarding.

You should remember from didactics why so many of the systemic autoimmune diseases cause joint pain. It has to do with the fact that joint spaces and cartilage are not vascularized, and depend on rapid diffusion from the synovial tissues, which are fed by fenestrated capillaries. Remember that this tissue, unlike most areas in the body, lacks a basement membrane to facilitate exchange into the joint space, including the exchange of large proteins, which are otherwise filtered out in other areas of the body. One downside is that in many cases of systemic inflammation, the synovium is more susceptible to the accumulation of proteins that leads to an inflammatory response in the joint space. This is an independent mechanism than diseases where the autoimmune response is specific for connective tissue around the joint.

Joint pain is typically referred to rheum to dx if the process is immune mediated if that is what is suspected.. If it is not, and it's just good old fashioned damage, like would be managed by ortho or sports med, than that is where that would be referred.

So to act like "joint pathology" is an overlap between rheum, ortho, and sports med, is sort of missing the point.

EDIT: I see above poster mentioning quite a bit of joint pathology that is not immune mediated being managed by rheum. My understanding is that this is more by accident than by design.
 

drfunktacular

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You should remember from didactics why so many of the systemic autoimmune diseases cause joint pain. It has to do with the fact that joint spaces and cartilage are not vascularized, and depend on rapid diffusion from the synovial tissues, which are fed by fenestrated capillaries. Remember that this tissue, unlike most areas in the body, lacks a basement membrane to facilitate exchange into the joint space, including the exchange of large proteins, which are otherwise filtered out in other areas of the body. One downside is that in many cases of systemic inflammation, the synovium is more susceptible to the accumulation of proteins that leads to an inflammatory response in the joint space. This is an independent mechanism than diseases where the autoimmune response is specific for connective tissue around the joint.
This is a compelling and logical explanation although it bears pointing out that it remains largely theoretical. "Why does rheumatoid arthritis affect the joints?" is actually an open question

Joint pain is typically referred to rheum to dx if the process is immune mediated if that is what is suspected.. If it is not, and it's just good old fashioned damage, like would be managed by ortho or sports med, than that is where that would be referred.

So to act like "joint pathology" is an overlap between rheum, ortho, and sports med, is sort of missing the point.

EDIT: I see above poster mentioning quite a bit of joint pathology that is not immune mediated being managed by rheum. My understanding is that this is more by accident than by design.
I'm sure most rheumatologists (myself included) would be more than happy to just manage inflammatory pathology and dismiss all the non-inflammatory pathology to be managed by others. In the real world, unfortunately, it just doesn't work that way so we do end up managing a lot of osteoarthritis, fibromyalgia, and soft tissue rheumatism




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IMreshopeful

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You know, in all fairness there are always lots of boring things seen by specialists. For Rheum it's the normal OA, bursitis, fibromyalgia stuff. For GI it's IBS, for cards it's stable CAD, etc. ultimately it ends up being your meal ticket
 

drfunktacular

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You know, in all fairness there are always lots of boring things seen by specialists. For Rheum it's the normal OA, bursitis, fibromyalgia stuff. For GI it's IBS, for cards it's stable CAD, etc. ultimately it ends up being your meal ticket
Yes this is completely true. It's something trainees don't like to think about because they imagine they will be out seeing/doing crazy, heroic, exotic stuff all day. Not so, unfortunately--most doctors spend like 80% of their time managing/monitoring stable, boring chronic conditions


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verok1943

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DrFunktacular, just out of curiosity, why are rheumatologists so poorly compensated compared to other IM fields? Is it unheard of for rheumatologists to make in excess of $400K+ post-tax ?

Also, thanks to you guys for enlightening me a bit on Rheum and Sports med. Even IF they're not related at all, I suppose if the doctor is willing and passionate enough, they could still practice both

And I'd just like to add, I'm an IMG in my 4th year of a 5yr program. It probably seemed before that I was more interested in sports injuries than Rheum so let me just clear that up a bit. Recently I went to a rheumatologist because of progressive pain and swelling in my 1st MTP joint over the course of a few days (made worse by LONG ward rounds). The rheumatologist thinks I have Gout or Pseudogout and so I spent a good bit of time reading in and around these conditions and found it fascinating. I'm still being worked up for those differentials but I've always believed its neither; I think it's hallux rigidus. I also saw a patient once on the ward with CREST syndrome and that, personally, was the most interesting patient I've seen to date. I like Sports medicine because i'm passionalte about health and fitness, and I've injured myself both in my wrist and my rotator cuff before.

I think our experiences tend to draw us to particular fields of specialty.
 
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verok1943

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I'm not sure what you mean by managing all of these musculoskeletal disorders "non-operatively"
I just wanted to stress the fact that I have no interest in orthopedic surgeries so I didn't want people to suggest that lol
Of course conservative treatment should always precede thoughts of surgery
 
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verok1943

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Many patients get referred to a rheumatologist for "arthritis" who just have rotator cuff disease, knee OA, trochanteric bursitis, etc so we end up managing a lot of those things without ever involving an orthopedic surgeon
I would not mind this at all!! This sounds similar to the kind of practice mixture I'm asking for
 

drfunktacular

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I would not mind this at all!! This sounds similar to the kind of practice mixture I'm asking for
Keep in mind though that rheumatology involves many other things as well

We are the primary managers of lupus, vasculitis, psoriatic arthritis, ankylosing spondylitis, crystalline arthritis, etc. So it's not all just musculoskeletal medicine


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ArkansasMed

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Maybe he is onto something. If he does both he can be the doctor who speaks during the psoriatic arthritis Embrel commercials while playing golf with Phil Mickleson and Chris Bosh.
 

dozitgetchahi

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Joint pain is typically referred to rheum to dx if the process is immune mediated if that is what is suspected.. If it is not, and it's just good old fashioned damage, like would be managed by ortho or sports med, than that is where that would be referred.
Ha!!! As a current rheum fellow I can tell you this is NOT actually the case...

That said, I can tell you that what gets most of us revved up in the mornings is the aforementioned autoimmune stuff...vasculitis, myositis, FMF, RA, etc etc. A good case of gout is always fun too - usually very satisfying to treat. Being able to knock out somebody's gigantic tophi with pegloticase is downright amazing.

Just as long as it's not fibromyalgia. Nobody really likes fibromyalgia.
 

drfunktacular

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Ha!!! As a current rheum fellow I can tell you this is NOT actually the case...
Yep. We get "stuck" with lots of stuff we're no better at managing than anybody else (FM, back pain, knee OA)

You learn this pretty quickly when you try to "release" a FM patient back to their PCP... 6 months tops before they get sent back with a RF of 19 or ANA 1:40 or just anything else the PCP can think of to make it your problem again


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Pixiwoman

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Anybody knows when the ABIM/ RHEUM exam results will be out? im nervous about it :nailbiting::smack:
 
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