So you want to be a rheumatologist. You like to solve complex puzzles and go through a lot of trial and error with your patients. Let’s debunk the public perception myths and give it to you straight. This is the reality of rheumatology.
Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as rheumatology, and help you decide if it’s a good fit for you. You can find the other specialties on our So You Want To Be playlist. If you want to vote in upcoming polls to decide what future specialties we cover, make sure you are subscribed.
What is Rheumatology?
Rheumatology is the specialty of medicine focused on musculoskeletal problems and autoimmune diseases, where the body’s immune system is dysfunctional, and the body basically attacks itself.
Rheumatology can often be described as “Internal Medicine Plus” because autoimmune diseases are often systemic and can affect any part of the body; so you need to maintain all of your internal medicine knowledge and then some.
Rheumatologists treat a wide variety of conditions. The complex conditions students and trainees encounter in the hospital may not be the conditions you most commonly see, but they’re the ones people are drawn to, like lupus, vasculitis, rheumatoid arthritis, and more. That said, the bread and butter of rheumatology can vary based on practice location and type of practice.
This brings us to an important method of differentiation: academic vs community vs private practice.
Academic vs Community vs Private Practice
In the academic setting, rheumatologists will divide their time between clinical, teaching, and research responsibilities. Academic rheumatologists are much more research-focused than their private practice counterparts, and you’ll often find rheumatologists who follow the physician-scientist track to dedicate more time to lab research or translational research. Academic rheumatologists are also more likely to see rare, complicated patients in the hospital.
As a private practice or community-based rheumatologist, you will spend the majority of your time seeing patients in the clinic. The most common conditions you will encounter include osteoarthritis, osteoporosis, rheumatoid arthritis, lupus, pain syndromes like fibromyalgia, and more. Many of the conditions you see in clinic will be much more straightforward than in academia. While not as much of a focus, you can still spend time in private practice teaching students and residents or being involved in research.
In terms of compensation, academic rheumatologists typically make less than their private practice counterparts, but this can often depend on other factors as well, such as location and research funding from grants.
Misconceptions About Rheumatology
Let’s clear up some of the misconceptions about rheumatology.
One big misconception is that all rheumatologists do is give steroids. While they do give corticosteroids frequently, it’s not the only medication they use. In the past thirty years, new biologic medications completely changed the game for both doctors and patients.
This actually leads us to our next misconception, which is that rheumatology patients are always in pain and don’t get better. With these biologic medications, patient outcomes are greatly improving to the point where new rheumatology trainees aren’t seeing late complications of rheumatoid arthritis anymore. Diseases like RA are no longer considered a sentence of disability for patients.
In addition, many people perceive rheumatologists as nerdy or slow to act. Rheumatologic diseases are often very complex, and physicians need to go through a lot of documentation and labs when working up their patients.
Even in rheumatologic emergencies, it’s usually not the rheumatologist that’s coming in to save the day at first. The emergency itself is usually managed by another team, whether it’s cardiology, critical care, or surgery, and then rheumatology will come in afterward to treat the underlying condition.
Rheumatologists are often called in when no one knows what’s going on, stepping into the role of the doctor’s doctor. And with the constantly evolving medications, rheumatologists have to stay up-to-date with the latest research.
How to Become a Rheumatologist
To become a rheumatologist, you must first complete four years of medical school, followed by three years of internal medicine residency, and, usually, two years of rheumatology fellowship. Some programs offer a three-year fellowship to make time for more research, while other programs offer combined training that includes allergy and immunology. If you’re interested in becoming a physician-scientist, a three-year fellowship can set you up for success.
For those interested in going into pediatric rheumatology, the pathway is slightly different. After medical school, you must complete three years of pediatric residency followed by three years of pediatric rheumatology instead of two years. The reason it’s three years is pediatric rheumatology is mostly academic, and the fellowship requires more dedicated research time.
In terms of competitiveness, internal medicine and pediatrics are among the 10 most attainable medical specialties. According to our analysis, internal medicine is the 9th least competitive specialty, and pediatrics is the second least competitive specialty, only behind family medicine. But don’t let these rankings fool you. If your goal is to match into a top-tier internal medicine or pediatrics residency, you will still need to do well on your Step exams and obtain ample research experience.
That said, rheumatology is one of the more attainable internal medicine fellowships. According to the 2019 Fellowship Competitiveness Index proposed by Tran et. al, rheumatology was the fifth most competitive IM fellowship, trailed only by endocrinology, infectious disease, and nephrology.
Competitiveness is increasing for multiple reasons. First of all, the introduction of biologics, which has led to improved patient outcomes, has attracted many trainees.
Secondly, the importance of work-life balance has increased for many people, and rheumatology is traditionally considered a specialty with a better work-life balance and very rare emergencies. In fact, in 2022, there were approximately 1.3 applicants per position. Most positions filled up, with a fill rate of 97.8%.
As for the type of medical student who typically goes for rheumatology, they are usually more laid-back students who prefer spending their time thinking rather than doing. Students who enjoy the art of piecing together different components of medical context to come to a conclusion generally enjoy rheumatology.
Subspecialties within Rheumatology
Unlike many specialties, most rheumatologists don’t pursue additional training after fellowship. However, for those who want to focus on a specific disease or area within rheumatology, that path is typically straightforward. The solution is usually to stay in academia and focus on your interests by doing more research in that field and learning from mentors.
For example, you can become the lupus specialist or scleroderma specialist at your institute. If you’re interested in Med/Peds, you can specialize in transition care, helping adolescents with rheumatologic diseases transition between adolescence and adulthood.
What You’ll Love About Rheumatology
There’s a lot to love about rheumatology.
To start, if you love the patient care aspects of being a physician, few specialties allow you as much time with patients as rheumatology. As a rheumatologist, you get to build long-term relationships with most of your patients.
You won’t simply treat a disease. When patients start to suffer from autoimmune diseases, they often feel like they are losing control of their life and body, which can be scary for them. Their body is literally attacking them. You’ll be able to help them regain a sense of autonomy and navigate a very vulnerable point in their life through treatment and education.
Furthermore, rheumatology is a much more creative specialty than other internal medicine specialties. While many specialties have much more straightforward diseases and algorithmic management plans, there’s a lot more grey area in rheumatology.
Diagnostic biomarkers and classification criteria do exist for certain diseases, but the story is often vague. Helping patients maneuver through this grey area by going through their documentation and lab findings is an art. The same goes for treatment, too. Since rheumatology is not as algorithmic, there’s a lot more room for personalization and shared decision-making with your patients.
In terms of lifestyle, rheumatologists have a good work-life balance. There are very few emergencies for rheumatology, and even then, rheumatologists aren’t called in during the middle of the night. In fact, in 2019, rheumatology was the top-ranked specialty in happiness outside of work, according to Medscape’s Physician Lifestyle & Happiness Report.
What You Won’t Love About Rheumatology
While rheumatology is an awesome specialty, it’s not for everyone.
To start, it’s a clinic-heavy specialty. If you’re not someone who can tolerate the day-to-day of clinic life, rheumatology may not be for you. Additionally, the volume of patients in the clinic can wear you down for multiple reasons. You need to figure out how to manage the high volume of patients without compromising their care. A high volume of patients also means managing a lot of relationships, which can weigh certain people down.
Like many specialties, and especially the internal medicine specialties, rheumatology has its fair share of administrative burden. Rheumatologists have to do comprehensive chart reviews and extensively document everything they do with their patients.
There are also many hoops you need to jump through when it comes to insurance companies. With new biologics, you first need to find data supporting the use of these medications. After that, you need to convince the insurance company to allow your patients to use these drugs.
You might spend hours curating a personalized management plan for your patient, only for them to have their request refused by their insurance company after they leave the clinic. This leads to a great deal of frustration for all of the involved parties and results in a lot of extra paperwork.
If you’re uncomfortable with grey areas, rheumatology may not be the field for you. Since these diseases are multi-systemic, each patient can present differently, with different signs, symptoms, and labs. Patients won’t respond to the same medications equally, and you just have to keep experimenting. Occasionally, patients won’t get that much better no matter how hard you try, which can be extremely frustrating and demoralizing.
Lastly, rheumatology is a specialty more suited for thinkers, not doers. There aren’t many procedures in rheumatology. While some rheumatologists do joint injections or become adept at musculoskeletal ultrasound, there isn’t much else outside of that. Unfortunately, this is reflected in compensation. In 2022, rheumatologists earned approximately $290,000 a year on average, ranking just above the internal medicine specialties of endocrinology and infectious diseases.
Should You Become a Rheumatologist?
How can you decide if rheumatology is right for you?
If you enjoy the cognitive aspects of medicine and want a specialty where you can spend your time solving complex puzzles, rheumatology may be the field for you.
You should enjoy spending time building strong, long-lasting connections with your patients and helping them regain their sense of self.
And if you prioritize work-life balance, rheumatology won’t make you choose between your family or work.
Are you hoping to become a rheumatologist? To get into medical school, match into an internal medicine residency, and get into a rheumatology fellowship, you’ll need to score well on your class tests and standardized exams.
As you look at resources and companies to work with, seek out those who are actual physicians, not Ph.D. or other types of doctors who didn’t go to medical school. Look for those who have achieved stellar results themselves, a track record of success with positive ratings from customers, and a systematic approach, so you know you’ll always receive high-quality service.
If you decide on Med School Insiders, we’d love to be a part of your journey to becoming a physician.
If you enjoyed this guide, check out So You Want to Be an Internal Medicine Doctor or another specialty in our So You Want to Be series.
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I Will Watch this video!!