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medicinehopeful

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hey all,
i know this has been brought up already, but some of the threads are a little outdated. i'm thinking about rheumatology as a career and am wondering about job outlook. how hard/easy is it to get a rheumatology job after fellowship? what is the avg starting pay? how is private practice? are infusion therapies still popular?
 

drfunktacular

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I am also curious about rheum... I am really interested in auto-immune diseases a la SLE, but things like OA and RA don't really do it for me (and fibro... yikes). Is it possible to be a rheumatologist and focus particularly on the immunologic aspects of diseases like SLE?
 
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hey all,
i know this has been brought up already, but some of the threads are a little outdated. i'm thinking about rheumatology as a career and am wondering about job outlook. how hard/easy is it to get a rheumatology job after fellowship? what is the avg starting pay? how is private practice? are infusion therapies still popular?

Rheumatology is a growning field, mainly driven by the new biologics. It is currently a "buyers market", and our rheum fellows get multiple offers. I can't comment on salary. Infusions = $$$$ although that may change.

I am also curious about rheum... I am really interested in auto-immune diseases a la SLE, but things like OA and RA don't really do it for me (and fibro... yikes). Is it possible to be a rheumatologist and focus particularly on the immunologic aspects of diseases like SLE?

It's hard to focus on a single disease unless you work in an academic center and do research in a field. Most practicing rheumatologists will manage large amounts of fibromyalgia, just like most prive gastroenterologists will manage dyspepsia, constipation, and chronic functional diarrhea.
 

KLycos

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Would like to know more about this in 2014.
 
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bronx43

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Would like to know more about this in 2014.
I'm not a rheum fellow, but my buddy who just finished fellowship signed a contract for around $300k about 40 minutes outside a mid-sized Midwestern city. He is commuting. He sees patients 4 days a week, and takes no call. Biologics and infusion centers are definitely becoming a big part of rheum PP as most large groups are offering them now, and I expect this to increase even more, as more meds are in the pipelines. I believe that rheum is where heme/onc was 10-15 years ago as far as field advancement. Obviously, I don't expect the same financial outcome as heme/onc in the late 90s. Rheum is becoming a great option for residents, as it's becoming more financially attactive and it's a 8-5 job with minimal call and almost no emergencies.
 

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I'm seriously considering IM into rheum at this point. I'm only a month into MS3 but I've seen a lot and thought hard about a lot of specialties - Rheum is looking really good at this point. I just wish it wasn't so hard to get info about what rheum is like day to day for residents and attendings in rheum.
 

drfunktacular

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I can answer specific questions about rheum if anyone has them.

Fellowship is great. Pretty chill most places. Clinic & hospital consults. Share call with co-fellows. I never once had to come in after hours for a consult, and usually would only get 2-4 on a whole call weekend at a large academic program (2 hospitals covered, combined ~1200 beds). Call for us was 1 in 6 weekends. On call, you might also get a few patient phone calls ("can I drink 10 beers while I'm on methotrexate?" "uhh.. no, thanks for calling" ... "I have a fever and I'm coughing up blood" "OK, go to the ER. The consult fellow will see you tomorrow"). No primary admissions, no ER consults.

I have just started my first "real" job, and it is almost entirely clinic patients, 8-5ish, call is 1 in 5 weekends, again mainly just patient calls and once in a blue moon a hospital consult that can't wait to be seen as an outpatient (most can, actually). Outside of academic centers, virtually no rheumatologists go to the hospital on a regular basis unless they are like me and trying to build up their practice. Infusions and IV treamtents are done in the office, and if patients need hospitalization for an infection, renal failure, etc, they go to a hospitalist who will just ask you what needs to be done over the phone.

The shortage of rheumatologists in most places is such that you can find a job pretty much anywhere except for the most major metro of major metro areas, and even then you can probably get a job if you sacrifice starting pay a bit. The other advantage of shortage is that if you don't want to see OA, fibro, and other assorted ouchies, you don't really have to. I choose to because a not insignificant number of those people will actually turn out to have RA, gout, SLE, etc that everyone else missed. Also, they are legion in number and are a good way to build your practice fast and get word of mouth referrals (assuming you are a good listener and nice to them).

Otherwise you get to see lots of really great, interesting stuff in rheum. Vasculitis, weird mononeuritis, multisystem inflammatory problems that nobody else can figure out. If you like puzzles, interesting cases, and an extremely wide diversity of pathologies, rheum is a great field for you. If you want to look at stool on a TV screen all day then drive home in your Maserati, it may not be for you. One of my attendings used to say "if you don't love a good gout case, you shouldn't be a rheumatologist" and that is true. I would also say if a patient with fever, weird lab results, a rash, and arthritis doesn't get you jazzed up, rheum may not be for you either. Rheumatology has also changed dramatically in the last 15 years with the introduction of biologics. The era of making a bunch of moolah off of infusions is pretty much over, but what remains is that we are actually able to make dramatic improvements in things like RA and vasculitis that just weren't possible a generation ago.
 
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bronx43

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I can answer specific questions about rheum if anyone has them.

Fellowship is great. Pretty chill most places. Clinic & hospital consults. Share call with co-fellows. I never once had to come in after hours for a consult, and usually would only get 2-4 on a whole call weekend at a large academic program (2 hospitals covered, combined ~1200 beds). Call for us was 1 in 6 weekends. On call, you might also get a few patient phone calls ("can I drink 10 beers while I'm on methotrexate?" "uhh.. no, thanks for calling" ... "I have a fever and I'm coughing up blood" "OK, go to the ER. The consult fellow will see you tomorrow"). No primary admissions, no ER consults.

I have just started my first "real" job, and it is almost entirely clinic patients, 8-5ish, call is 1 in 5 weekends, again mainly just patient calls and once in a blue moon a hospital consult that can't wait to be seen as an outpatient (most can, actually). Outside of academic centers, virtually no rheumatologists go to the hospital on a regular basis unless they are like me and trying to build up their practice. Infusions and IV treamtents are done in the office, and if patients need hospitalization for an infection, renal failure, etc, they go to a hospitalist who will just ask you what needs to be done over the phone.

The shortage of rheumatologists in most places is such that you can find a job pretty much anywhere except for the most major metro of major metro areas, and even then you can probably get a job if you sacrifice starting pay a bit. The other advantage of shortage is that if you don't want to see OA, fibro, and other assorted ouchies, you don't really have to. I choose to because a not insignificant number of those people will actually turn out to have RA, gout, SLE, etc that everyone else missed. Also, they are legion in number and are a good way to build your practice fast and get word of mouth referrals (assuming you are a good listener and nice to them).

Otherwise you get to see lots of really great, interesting stuff in rheum. Vasculitis, weird mononeuritis, multisystem inflammatory problems that nobody else can figure out. If you like puzzles, interesting cases, and an extremely wide diversity of pathologies, rheum is a great field for you. If you want to look at stool on a TV screen all day then drive home in your Maserati, it may not be for you. One of my attendings used to say "if you don't love a good gout case, you shouldn't be a rheumatologist" and that is true. I would also say if a patient with fever, weird lab results, a rash, and arthritis doesn't get you jazzed up, rheum may not be for you either. Rheumatology has also changed dramatically in the last 15 years with the introduction of biologics. The era of making a bunch of moolah off of infusions is pretty much over, but what remains is that we are actually able to make dramatic improvements in things like RA and vasculitis that just weren't possible a generation ago.
Thanks for the response.

Question about biologics. You say that the era of making a bunch off infusions is over. Are you referring to the old heme/onc docs selling drugs and giving them at their own infusion suites? Cuz, as far as I can remember, rheum never made a bunch of moolah from anything... Also, how much income can you expect from infusions? Is it even financially viable?

What are the typical starting offers that you saw from non-big cities? My buddy landed a gig (45 min from a medium sized city in the MidWest) for $260k base + bonus for 4 clinic days a week and one day of paperwork.
 

drfunktacular

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Thanks for the response.

Question about biologics. You say that the era of making a bunch off infusions is over. Are you referring to the old heme/onc docs selling drugs and giving them at their own infusion suites? Cuz, as far as I can remember, rheum never made a bunch of moolah from anything... Also, how much income can you expect from infusions? Is it even financially viable?

What are the typical starting offers that you saw from non-big cities? My buddy landed a gig (45 min from a medium sized city in the MidWest) for $260k base + bonus for 4 clinic days a week and one day of paperwork.

In the late 90s Remicade was the only available TNF inhibitor. RA affects ~2% of the population. Before recent MC rule changes, docs could (basically) buy Remicade at wholesale price then charge the patient's insurance retail price + percentage for infusion. Mucho dinero. There are more than a few millionaire rheumatologists running around who took great advantage of this scheme in the good old days. You can still do ok on infusions for now but only if you do a huge volume of them. Hence there are some sort of shady folks who start every RA patient on infusion meds from the get-go even though Humira and Enbrel have been around for more than a decade. Most people don't bother anymore, or if they still have an infusion room it's because they more or less break even and they do it because it's more convenient for patients than going to get infused at the hospital.

My deal is similar to what you mentioned; my base pay is lower but there's a production bonus and very short path to partnership. Starting pay tends to be lower in big cities (180-230k) and much lower in academics (~120k). But if you're planning to do this for a long time you should be focusing on the long term (partnership, profit sharing, etc) not your pay for the first couple of years. Find a group that you like and seems fair and easy to work with--don't focus too much on starting pay, because in the grand scheme of a long-term, solid career it's pretty unimportant.


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bronx43

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In the late 90s Remicade was the only available TNF inhibitor. RA affects ~2% of the population. Before recent MC rule changes, docs could (basically) buy Remicade at wholesale price then charge the patient's insurance retail price + percentage for infusion. Mucho dinero. There are more than a few millionaire rheumatologists running around who took great advantage of this scheme in the good old days. You can still do ok on infusions for now but only if you do a huge volume of them. Hence there are some sort of shady folks who start every RA patient on infusion meds from the get-go even though Humira and Enbrel have been around for more than a decade. Most people don't bother anymore, or if they still have an infusion room it's because they more or less break even and they do it because it's more convenient for patients than going to get infused at the hospital.

My deal is similar to what you mentioned; my base pay is lower but there's a production bonus and very short path to partnership. Starting pay tends to be lower in big cities (180-230k) and much lower in academics (~120k). But if you're planning to do this for a long time you should be focusing on the long term (partnership, profit sharing, etc) not your pay for the first couple of years. Find a group that you like and seems fair and easy to work with--don't focus too much on starting pay, because in the grand scheme of a long-term, solid career it's pretty unimportant.


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Thanks again for the response.

Then, do you see any financial benefit from the fact that SO many new biologics and other rheumatologic drugs are out on the horizon? I've heard countless times that rheumatology is set to explode, but do you think any of that can be transformed into good revenue for a practice? Also, what are the big money makers for rheumatology? In other words, when you make partner, is it really that much better in terms of profit/salary?
 

drfunktacular

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Thanks again for the response.

Then, do you see any financial benefit from the fact that SO many new biologics and other rheumatologic drugs are out on the horizon? I've heard countless times that rheumatology is set to explode, but do you think any of that can be transformed into good revenue for a practice? Also, what are the big money makers for rheumatology? In other words, when you make partner, is it really that much better in terms of profit/salary?

Not in infusions. Honestly for 95% of RA patients the existing biologics work very well. A lot of the drug development going on there is "me too" development. The big things in a practice financially are owning your own lab and imaging, and making sure that you are coding appropriately... Rheumatologists are often "under coders" and miss out on money they should get based on the complexity of patients and amount of counseling and coordinating we do


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Owning ur own lab and imaging, great to see someone making their own moves rather than having their science spoon fed to them

I think lab and imaging equipment should be getting cheaper and more practical in terms of size as well. Equipment financing in medicine is very easy to obtain through a sba loan with good terms and favorable tax amortization. Besides the initial upfront tax deduction u can take when starting a practice for it

Have a practice in an office complex where u can get referral from other practices to take business away from lab corp. Hire a phelobotomist and later a tech if referrals become substantial, both low paid jobs by hospitals/lab corp u can find good people for

Beyond that municipal and city contracts are obtainable where u can provide all the initial employee health screening. TB, vaccines, blood work for those employed by schools, fire, police. This money is guranteed and paid up front quarterly based on per person basis. It can be a lifesaver when insurance payments lag behind while overhead costs accrue

Small businesses have preferential treatment when bidding for contracts and some are exclusively theirs. Plus labcorp/quest do not provide their services any cheaper than u can given adequate capacity
 
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I can answer specific questions about rheum if anyone has them.

Fellowship is great. Pretty chill most places. Clinic & hospital consults. Share call with co-fellows. I never once had to come in after hours for a consult, and usually would only get 2-4 on a whole call weekend at a large academic program (2 hospitals covered, combined ~1200 beds). Call for us was 1 in 6 weekends. On call, you might also get a few patient phone calls ("can I drink 10 beers while I'm on methotrexate?" "uhh.. no, thanks for calling" ... "I have a fever and I'm coughing up blood" "OK, go to the ER. The consult fellow will see you tomorrow"). No primary admissions, no ER consults.

I have just started my first "real" job, and it is almost entirely clinic patients, 8-5ish, call is 1 in 5 weekends, again mainly just patient calls and once in a blue moon a hospital consult that can't wait to be seen as an outpatient (most can, actually). Outside of academic centers, virtually no rheumatologists go to the hospital on a regular basis unless they are like me and trying to build up their practice. Infusions and IV treamtents are done in the office, and if patients need hospitalization for an infection, renal failure, etc, they go to a hospitalist who will just ask you what needs to be done over the phone.

The shortage of rheumatologists in most places is such that you can find a job pretty much anywhere except for the most major metro of major metro areas, and even then you can probably get a job if you sacrifice starting pay a bit. The other advantage of shortage is that if you don't want to see OA, fibro, and other assorted ouchies, you don't really have to. I choose to because a not insignificant number of those people will actually turn out to have RA, gout, SLE, etc that everyone else missed. Also, they are legion in number and are a good way to build your practice fast and get word of mouth referrals (assuming you are a good listener and nice to them).

Otherwise you get to see lots of really great, interesting stuff in rheum. Vasculitis, weird mononeuritis, multisystem inflammatory problems that nobody else can figure out. If you like puzzles, interesting cases, and an extremely wide diversity of pathologies, rheum is a great field for you. If you want to look at stool on a TV screen all day then drive home in your Maserati, it may not be for you. One of my attendings used to say "if you don't love a good gout case, you shouldn't be a rheumatologist" and that is true. I would also say if a patient with fever, weird lab results, a rash, and arthritis doesn't get you jazzed up, rheum may not be for you either. Rheumatology has also changed dramatically in the last 15 years with the introduction of biologics. The era of making a bunch of moolah off of infusions is pretty much over, but what remains is that we are actually able to make dramatic improvements in things like RA and vasculitis that just weren't possible a generation ago.

How much does genetic knowledge play a role in being a good rheumatologist?
 

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Can anyone offer info on further advanced fellowship opportunities after completing a rheum fellowship? For example non-anesthesia pain management, etc?
 

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Usually fellows do not go onto advanced fellowships. If a fellow has a particular interest, they are hopefully at an institution that has someone with an interest in that field and they pair with them and do research and establish their own research agenda. There may be a few advanced fellowship opportunities but they are not boarded/recognized and likely not needed.

In terms of pain management, rheumatologists (at least where I am), do less of this. We tend to defer pain management to primary care or pain specialists and treat the cause of their pain. If your primary interest is pain management, skip the rheum fellowship! Go into rheum if you are interested in immunology and management of patients with gout, lupus, and rheumatoid arthritis and the really interesting/new/cool stuff as described above by drfunktacular.
 

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How much does genetic knowledge play a role in being a good rheumatologist?

Pretty much none. Other than disease association with specific genotypes/ HLA alleles or rare inflammatory syndromes.
 
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