The Cerebral Field of an Academic Rheumatology


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SS 139: The Cerebral Field of an Academic Rheumatology

Session 139

What do House and rheumatologists have in common? Dr. Anisha Dua, fellowship director at Northwestern Medicine, answers and talks lifestyle, dispels myths, and more!

Anisha is an academic rheumatologist who’s been out of her fellowship now for nine years (eight years as of this recording). For more resources, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:16] Interest in Rhemuatology

Anisha took an elective during her fourth year and she loved the doctors she worked with. She considered critical care a bit. But she was drawn to rheumatology because it was algorithmic. You learned about the patients and you had long term care. So it was her intern year of residency where she was definitely set on rheumatology.

The more she learned about them, the more it became more just a pattern. Rheumatology was seen in more of a black box, and  confusing. But the more you learned about it, the more interesting it became.

'It wasn't something that you could just follow a straight pattern about.'Click To Tweet

It constantly challenged her to think about what the patients are telling her, what blood tests she’s ordering, what their exposures are. She’s just trying to put together the pieces of a puzzle as opposed to following just a preset plan.

[03:12] The Biggest Misconceptions Around Rheumatology

A lot of people don’t know exactly what it is. But now, there’s more awareness just because of  commercials and new drugs that are available for different rheumatic diseases.

There’s a misconception that it’s just managing chronic pain, which is not. Once people start talking about autoimmune diseases and connective tissue diseases, sometimes people just get overwhelmed. They’re not  sure what that means, because it’s not one organ.

“There's just misconception about what exactly it is they do or treat.”Click To Tweet

[04:02] Traits of a Good Rheumatologist

You have to listen to patients and put together pieces of the puzzle. It’s having that mindset of trying to be a detective. Think outside the box because it’s not just one organ. You need to collaborate with other subspecialties, whether it’s in medicine or surgery. They do a lot of discussions with different specialists and provide the best care to patients.

“Being open to talking to people, being excited about communicating with other specialists, and listening to the patient are things that are important.”Click To Tweet

[05:03] Types of Patients

Anisha’s focus is on vasculitis so she sees a lot of that disease state. Other cases include autoimmune diseases and connective tissue diseases. They see things like rheumatoid arthritis, psoriatic arthritis, lupus, scleroderma. She sees a lot of different overlap types of conditions.

The more bread and butter stuff would be rheumatoid arthritis, gout, and osteoarthritis.

“A lot of what they manage are disease states where your immune system is going haywire and attacking different parts of your body for some reason.”Click To Tweet

In terms of the percentage of patients where they are actually trying to figure out what’s going on versus they’re coming to them already diagnosed.

Anisha thinks one of the big things is listening and figuring out whether that diagnosis fits those patients who are coming from outside places. So it’s still exciting and challenging.

“They're coming for an opinion because they're either not doing well or they're not responding to therapies.”Click To Tweet

Anisha says they’re a very cerebral field. She makes a lot of new diagnoses, probably half are new diagnoses. But even those that are already diagnosed, she had to change the diagnosis or change the treatment plan. 

There’s a lot of decision making that happens because some of the symptoms are pretty vague. And some primary care doctors aren’t quite sure how to interpret those lab tests.

The ANA is a test that’s ordered often and It’s something that can lead to a lot of patient anxiety when it’s positive. And when it’s ordered in a way that’s maybe not indicated, it can result in a lot of downstream costs and a lot of patient anxiety.

So from the rheumatology perspective, they try to figure out if there’s something autoimmune or inflammatory going on? When you see a primary care doc, they are managing so many different pieces of things. And so to delve down into some of the nuances of what’s driving the joint pain or the rash or whatever it is that’s going on, it can be a lot. And those are the patients that primary care is sending over to them.

[08:57] Are There Procedures in Rheumatology?

Absolutely. That’s something that Anisha does a lot. They do a lot of aspirations of joint injections taking fluid out of different joints.

And increasingly, ultrasounds are being used a lot. They’re able to do a lot more of injections of deeper structures and things like that.

“We’re not going in and replacing the entire joint, but there are procedural pieces to it… so you do get to use your hands and do stuff.”Click To Tweet

It’s definitely more of an outpatient and mentally stimulating field. Some people do have procedure days where they do just ultrasound guided procedures for an entire day.

There is definitely the ability to tailor it the way that you’d like to, although you’re not going to go in and be cutting out organs.

[09:52] Taking Calls and Life Outside of the Hospital

Anisha has fellows and residents on her service. When she’s on call, she does four weeks of inpatient a year. And mostly it is in the evenings, it’s getting phone calls about patients. If there is anything that her fellows have questions about, otherwise, it’s not bad.

You do your clinic and you go and see the patients who are sick in the hospital and give your recommendations. Mostly, they’re talking about patients or figuring out the story with other sub specialists. There are some but there are very few rheumatologic emergencies where she would have to be called in the middle of the night to go in and do anything.

In terms of life outside of hospital, Anisha does a lot of teaching. She runs the training program, giving lectures, preparing talks, and doing some research in vasculitis. Outside of work, she does a lot of stuff like traveline, reading, sports, and pottery.

[12:48] The Training Path

After medical school, you do internal medicine residency, which is three years and at this time you apply during your third year of residency if you’re planning on going straight into fellowship.

Then there are two years of required ACGME Rheumatology fellowship. And then there are many programs. That’s an additional third year.

At her program, they offer two or three years. And most people who are interested in staying in academia or doing any clinical or other research will opt to do that third year. They stay to either get grant funding or participate in different types of map clinical master’s programs or educational fellowship programs.

[13:46] The Big Upheaval in the USMLE with the Pass/Fail System

Anisha claims they have become increasingly competitive. Now, they have become as competitive as GI and cardiology, essentially. So rheumatology has picked up a lot of interest.

When she’s looking at applications, she’s looking at them actually more in a pass-fail way. She evaluates whether the applicant has a pattern of not passing these exams. Because the numbers have been going higher and higher.

For her, the scores are fine. But they don’t quite assure that the applicant is going to be an asset to the field or be a good doctor or someone they would want to work with. 

“I’m looking for a lot more depth than what those scores that were provided anyway.”Click To Tweet

[15:42] What Makes a Competitive Applicant

The field has gotten increasingly competitive. Anisha would like to see some track record of showing interest in Rheumatology. That’s usually shown through either presentations at conferences or abstracts, posters. Of course, if they publish something that would be great. Or if they have some ideas of what they want to add to the field or what they want to do specifically.

Anisha says she looks a lot at letters of recommendation. She makes sure that they’ve worked in a rheumatology setting, and that’s what’s driving their decision, and that the people who they worked with thought that they’re brilliant in some way.

“Having strong letters of rec, having a track record of being consistently interested in Rheumatology, and then publications and some academic angle is something that I do look at.” Click To Tweet

Rheumatology is not a required rotation. Because of this, there are a lot of students who don’t find out about the field until later on. And so if students who suddenly are interested in the field and they don’t have a consistent research background, they just have to make that argument.

They have to make it clear as to why they changed their mind. For instance, you may have an advisor who’s a rheumatologist that you’ve rotated with that helped inspire you to make that decision or push that interest. They can send emails or letters on your behalf saying that you’re great but you don’t have the track record.

It’s not necessarily that they’ve had to publish in Rheumatology say you’ve been interested in gi for a long time, and you’ve done a presentation. It’s just showing that academic interest.

As long as you’ve shown it in whatever area and you can explain the leap between whatever you thought you might be going into and wanting to do rheumatology, that’s fine. 

As long as you can explain what drove that decision, and have shown that you’ve been committed as a medical learner before that point, regardless of what your interest was. That’s totally fair and it’s still competitive.

[19:18] Negative Bias Towards DOs

She doesn’t think that in Rheumatology there’s as much of a bias because a lot of the DO pathway and other training emphasizes some of the stuff that they’re interested in.

They have a good understanding of musculoskeletal disease, and she doesn’t think it’s necessarily a drawback or something that’s looked down. It comes back to more of just showing pursuit of academic stuff.

Whether or not you’re an MD or DO you can still present any of these medical types of meetings. Even if you’re giving conferences at your own institution or showing that you’re doing that and actively engaged in stuff is fair. So she hasn’t seen any bias whatsoever.

[20:50] Further Fellowships

There aren’t ACGME-specific fellowships. There is non acgme, T32, and NIH funded research years, etc. So if you do have an interest in a specific area of clinical research or translational research, there’s definitely pathways for that.

The American College of Rheumatology has great resources for people interested in pursuing research. Young investigators and also for residents and medical students interested in Rheumatology who may not have that expertise at their own institutions can gain experience. They can try to get their feet wet.

But in terms of her being interested in vasculitis, the Vasculitis Foundation has a fellowship for people who are interested in vasculitis. They can go to certain centers of excellence that have a high volume of vasculitis. It’s not super common when you just think about general medicine or general rheumatology.

“In order to be specialized in vasculitis, you want to have a high comfort level and see a lot of volume of those patients.” Click To Tweet

They’re not ACGME fellowships but you can pursue other types of specific training. A lot of it is just figuring out what you’re interested in and getting your name out there and seeing those patients. Whether it’s being involved in clinical trials or giving talks on the topic. Whatever it is, you get to carve out which area you’re gonna specialize.

Again, in general rheumatology, you don’t have to do that. And even in an academic center, you don’t necessarily have to have one area. 

But a lot of people do and it is another sub community which is fun. The vasculitis community is amazing and it’s a supportive group of people who are excited about the same stuff. So that always challenges you and makes you excited to get a little deeper in that area.

[23:06] Message to Primary Care Physicians

Anisha says it’s tough because people don’t quite know exactly what they’re doing. One of her pet peeves is over labeling patients because it’s hard to undo. And it can be dangerous.

Because then once the patient comes to see her, then she’s telling them that that might not be the case.

“It's a lot harder to undo a diagnosis than to get one.” Click To Tweet

Ansiha underlines the importance of ordering tests, to think about what you’re ordering and when you’re ordering. 

Communicating is important. If you have a specific question in mind that you want them to answer, patients come in and they don’t always know why they’re there. So trying to figure that out can be difficult when you’ve got a short visit with a patient.

And so, just explaining why they’re being sent to her, whether it’s to her or to the patient is very helpful. This way, she can give back the feedback that’s actually useful to the primary care doc and the patient.

[24:30] Should Only Rheumatologists Order ANA Tests?

There is definitely utility. It’s more about not having that high pretest probability. If you’re just ordering it willy-nilly, or if you’re just ordering it randomly on patients just to see, then it can just lead to a lot more anxiety and cost.

“It should be ordered with thought and with care.” Click To Tweet

It’s one of those tests that can lead to a lot of anxiety and people don’t know how to interpret it. And that’s fine. It’s not interpretable in its own right. It doesn’t give you any diagnosis.

The important part comes back to the patient’s story, clinical exam, other lab findings that are more specific. As long as there’s not a label given to someone based on one blood test.

Moreover, you don’t need to keep repeating the ANA test to find if it will go positive or negative. It’s just an extra test. Otherwise, that’ll drive up care costs and drive up anxiety and extra blood.

[27:06] Working with Other Specialties and Special Opportunities Outside of Clinical Medicine

Rheumatology can work with a lot of other specialties – pulmonary, nephrology, dermatology, and urology and then with subs with surgical subspecialties. Anisha does a lot with EMT because of the vasculitis and then also Opto and Ortho.

In terms of special opportunities outside of clinical medicine for rheumatologists, there’s so much happening in terms of discovery, pathogenesis, and targeted treatments.

“People are starting to recognize what rheumatology is, and that there's so much happening and going on that's exciting in the field.“ Click To Tweet

There’s breakthrough in terms of the medications they have available to offer their patients. Also on the research side, they’re trying to figure out the pathways and develop the stuff that becomes targeted and biomarkers. So there’s a lot in clinical research, basic science, translational research. And then obviously, there’s a huge workforce shortage.

The American College of Rheumatology has looked into that and published on it. They’re trying to expand the workforce with the aging population. With the new treatments, patients are living longer with their diseases and getting diagnosed earlier. So there’s a huge demand. The wait times are insane.

Outside of clinical medicine, there’s a lot. But also within clinical medicine with the shortage of rheumatologists, they do need more people to see patients. There are exciting opportunities in terms of  pharma and research as well.

[29:28] The Most and Least  Things About Rheumatology

Anisha already knew how awesome it was. She was lucky to get exposed to it early so she was able to get a good sense of what it entailed. Anisha loves a lot of things about rheumatology. She loves the team. She loves teaching. The patients are amazing. They’re so resilient.

“Rheumatology is a field where we still focus heavily and relied heavily on the story and the clinical exam.”Click To Tweet

What she finds so exciting is the fact that the diseases affect so many different organs. So she gets to collaborate with people in so many different fields, whether it’s surgical, or medical, or neurology or dermatology. And that leads to the best patient care.

On the flip side, one of the least rewarding parts or the frustrating part for her is arguing for approval. It’s coverage for getting the patients and medicines that she knows they need or want or should be on and then being told that they can’t get it for them is probably the most frustrating.

[31:39] Major Changes in the Future

There’s gonna be a lot more interest in targeted therapies. They are going to be using a lot more ultrasound and following their European colleagues for trying to make certain types of diagnoses. There’ll be advances in imaging and hopefully be advances in biomarkers. They will be incorporating the use of physician extenders a lot more just because of the workforce shortage.

“We're moving closer slowly towards the cancer world in terms of being able to actually figure out what medicine works best in which patient.” Click To Tweet

[32:48] Final Words of Wisdom

If she had to do it over again, Anisha says she still would have chosen Rheumatology.

Finally, she wishes to tell students who might be interested in Rheumatology to just do what makes you happy. You have to be honest to yourself. Stay positive.

Rely on each other. Rely on mentors and colleagues and etc. It’s an exciting time though,  everything is open to you. 

“Just step back and think about, is this something that I want to do every day? Are these the people I want to work with? Is this the type of setting I want?” Click To Tweet

Be honest with yourself and then and be excited about what you’re doing. Just figure out what makes you excited and then follow it.

Links:

Meded Media

The American College of Rheumatology

Vasculitis Foundation

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