What Life is Like as a Pediatric Rheumatologist

Session 188

Dr. Bryce Binstadt is a pediatric rheumatology fellowship director. Today, we talked about stereotypes, the different paths to becoming a ped rheumatologist, and more. Also, did you know that pediatric rheumatology training is actually longer than adult rheumatology training? Find out why!

If you think you might be interested in pediatric rheumatology, check out some resources at the American College of Rheumatology. For more podcast resources to help you with your medical school journey and beyond, check out Meded Media.

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

[01:08] Interest in Pediatric Rheumatology

Bryce was in a combined MD/Ph. D program. And in his final year of medical school, he did an away rotation at a different institution, in pediatric rheumatology, and just fell in love with it. His PhD was in immunology. So he was already interested in the science behind rheumatology. Then as he learned that the patients had these fascinating diseases, and got to have long term relationships with the patients, he found it was just a great fit.

He adds that around half the time, their research leads naturally into the specialty they choose clinically. And so, people just follow their heart in terms of choosing their clinical specialty.

[02:47] The Biggest Myths or Misconceptions Around Pediatric Rheumatology

'Many people feel that the diseases that we take care of are rare, and that's not necessarily true.'Click To Tweet

People think of Rheumatology as treating obscure diseases, particularly in childhood. But that’s not the case at all because they take care of many diseases where there are plenty of patients out there.

Juvenile arthritis is relatively more common than Type I diabetes, for instance. And so, there are patients out there that are doing so well that you can’t tell that they have arthritis these days.

[03:46] Traits that Lead to Being a Good Pediatric Rheumatologist

In rheumatology, whether it’s pediatric or adult, they take care of patients who have a multisystem of disease. People who are interested in multiple organ systems tend to gravitate toward rheumatology.

To be good in this specialty, you need to be attentive to detail, both in terms of history and taking an exam. You have to be thoughtful about the laboratory approach and in evaluating patients in differential diagnosis because they order tests that are unusual to most folks in other specialties. You have to geek out about what those tests are and what they mean.

'It's a combination of being interested in the whole patient and multiple organ systems, but also willing to dive deep and get into the nitty-gritty of disease pathogenesis and mechanism.'Click To Tweet

[04:51] Types of Patients

As a pediatrician, they take care of kids from birth until they head off to college or join the workforce. And so, it’s the entire age range.

They take care of patients with rheumatic diseases, including juvenile arthritis being the most common, as well as a host of other pediatric rheumatic diseases, juvenile dermatomyositis, pediatric lupus, and vasculitis. Then there are some particular pediatric ones that are not seen so commonly in adulthood such as Kawasaki disease.

The field has divided the diseases into autoimmune (juvenile arthritis), lupus, dermatomyositis, and auto-inflammatory diseases. Auto-inflammatory diseases are more driven by the innate immune system and periodic fever syndromes are in that category. It’s a wide range of diseases, mostly characterized by inflammation.

Their practice is primarily outpatient, although they see hospitalized patients. On the outpatient side, most patients come to them with vague symptoms or complaints.

The question for them is do they have rheumatic disease or not? And those that have rheumatic diseases are probably less than 25%.

A variety of others are musculoskeletal disorders or pain syndromes that can lead patients and their referring physicians to think this might be a rheumatic disease. But it is, again, probably fewer than a quarter that end up having rheumatic disease.

'Patience in waiting is something that a rheumatologist has to be comfortable with. The disease may not be fully manifest when we first see them, and it's time that helps us make the diagnosis.” Click To Tweet

[08:08] Typical Day

All pediatric dermatologists practice at academic centers and there are very few in private practice.

For his clinical colleagues, a typical day is spent in the clinic seeing outpatients, that are combined new patients and many return patients. They follow through patients with chronic diseases over time. And then someone in their group is always covering the inpatient service. And so, when it’s your week to cover the inpatient service, you’re doing that plus seeing your outpatients.

Bryce has less clinical time and has some time devoted to research and some administrative roles and education programs. He has one or two half days of clinic per week, and the rest of the time is spent on research or administrative activities.

One of the things he likes about this is based on your career interests. If you have an interest in being involved in research or being involved in education or administration, you can craft your practice within academia to do all of the things you want to do.

[09:54] Percentage of Procedures in Pediatric Rheumatology

20 years ago, the main procedure they used to do were intra-articular steroid injections, where they inject steroids into joints. And that’s because they had fewer options for systemic therapy.

But now with the advent of TNF inhibitors and other biologic medications that help control arthritis, they do far fewer joint injections, even maybe only do one procedure a month on average.

[10:32] Taking Calls and Life Outside of the Hospital

Calls would be like relatively a light week with a few phone calls from outside physicians. One is from an emergency department to talk through some patients. And then a couple of calls from patients and families at nighttime.

There are other call weeks though, where they have one or two hospitalized, very sick patients who may have a rheumatic disease that’s flaring. And they’re in the intensive care unit needing aggressive immunosuppression. This usually takes more time.

So the call varies week to week depending on how many hospitalized patients there are and how sick those patients are.

Bryce thinks pediatric rheumatology is definitely a specialty that lends itself toward good work life integration or balance. He’s still able to take care of himself and exercise, as well as make time for his two teenage kids’ activities.

[12:29] The Training Path

Right after medical school, general pediatrics residency is the next step or med-peds followed by subspecialty fellowship training.

It’s a three-year fellowship for most people. And some people extend it to do more research. But the board of pediatrics requires three years of fellowship training. And then after that, you’re good to go. You can take the board exam for pediatric rheumatology and get yourself a job.

If they’re only trained in internal medicine, going into pediatric rheumatology is not a likely viable path. But if they’re jointly trained in med-peds, then that certainly is a viable path.

Bryce directs the fellowship program at their institution. They have one trainee who is pursuing both pediatric and adult fellowship training. They have had one in the past, and there’s a few around the country at other institutions.

Providers who have finished this kind of training are very well suited to take care of the patients transitioning from pediatric to adult care. Late adolescence to early adulthood is a time in life when a lot of patients fall through the cracks. And so, having providers who do have the joint training is very helpful. They can really create a nice clinical setup for those transitioning patients.

[14:21] What Makes an Applicant Stand Out

Some people come to this specialty from an immunology research angle and they’re fascinated by the disease pathogenesis.

Other individuals are much more focused on the patients and their diseases and wanting to take care of kids who have chronic, treatable but not curable diseases. They watch those children grow up from being a two-year-old, newly diagnosed with a rheumatic disease to a thriving, healthy adolescent heading off to college.

It’s really rewarding to be involved in that patient’s life over that entire time span and help them along the way. So it’s a little bit different for each person.

Getting some experience with a field is crucial. Now, this can be challenging at some medical schools where there are no pediatric rheumatologists. And so, if you think you might be interested, it’s helpful to find an institution where you can work with a pediatric rheumatologist and get to know the field.

Also, try to engage in the American College of Rheumatology as they provide annual meetings that have special programs for students. This is also one way to demonstrate interest to a program director and that can happen when you’re a student or when you’re a resident in pediatrics.

[16:25] Does the Low Compensation Rate Make It a Less Attractive Specialty?

Typically, non procedure-based specialties aren’t known as the highest paid specialties. Then add pediatrics onto it, and then it lowers the compensation rate. And this is not the case on the adult side or for the procedural specialties.

Bryce thinks they lose good candidates because of that. But that doesn’t mean that the reason people are going into these other fields is that they want to make money. Obviously, people need to make enough to support their families and live comfortably.

Pediatric rheumatology is a three-year fellowship while adult rheumatology is a two-year fellowship. And so, it becomes a little bit less attractive that way. You have to put in one more year before you start earning the physician salary. This is one of the structural challenges right now and the field is trying to incentivize people to join the field. The plus side of that is people who choose the field of pediatric rheumatology do it because they love it. They’re not motivated by financial incentives.

“People who choose the field of pediatric rheumatology do it because they love it. They're not motivated by financial incentives.”Click To Tweet

[18:35] Why Pediatric Rheumatology Training is Longer Than Adult Training

Bryce says that most pediatric subspecialists are at academic centers, and are expected to engage in research. And so, the additional year of training is to get more research experience.

On the adult side, it’s quite easy to be a rheumatologist in community practice. There are many more patients on the adult side for bread and butter rheumatoid arthritis and whatnot. So those adult providers don’t have to be tied to academic centers. Whereas the pediatric folks tend to be tied that way to academic centers and need to develop a research portfolio or some academic portfolio, an additional skill set beyond the clinical practice.

[19:31] What Makes a Good Fellow

Bryce says they’re looking for fellows who have good communication skills where they take an interest in the patients.

“Rheumatologists have this reputation of sending a lot of tests.”Click To Tweet

Rheumatologists send a lot of tests so you have to have someone who you trust will follow up all of those test results that are hanging out. Therefore, teamwork is a big part of it.

Because the patients have chronic disease, a patient may be hospitalized for four weeks and alternate through different fellows and different attendings. And so, you want to know that the people you’re handing the service off to are going to take good care of the patient. You want them to be clinically excellent, follow through, and know they’ll take good care of your patient.

Bryce hopes all doctors aspire to take good care of patients, to be trustworthy, and to play well in the sandbox with everyone else. And recognize that at the end of the day, their job is to take care of the patients to the best of their ability.

[21:13] Special Opportunities to Subspecialize Once Done with Rheumatology Fellowship

Some people pursue combined training in pediatric rheumatology as well as allergy and immunology if they’re more interested in the genetic diseases, immunodeficiencies, and autoinflammatory syndromes.

There are some pediatric rheumatologists who gain additional certification in sports medicine, or certification and ultrasound. But those are more certificate-based experiences rather than another fellowship.

“Most pediatric rheumatologists don't pursue additional training after their fellowship.”Click To Tweet

[22:21] Message to Future Pediatricians

Bryce’s advice to future pediatricians to find their closest pediatric rheumatologist. For a lot of general pediatricians, there are parts of the country where patients have to drive hundreds of miles to find a pediatric rheumatologist.

If pediatricians are practicing in those areas, it’s particularly important for them to know where the pediatric rheumatologists are and how to reach out to them.

Bryce says they’re a friendly bunch and they appreciate getting calls from general pediatricians. They want to help take care of the patients the sooner. For instance, for a patient with juvenile arthritis, the sooner they start on therapy, the better the long term outcome.

[23:36] Other Specialties They Work the Closest With

They take care of multi organ diseases, so they get to interface with almost every other specialty within pediatrics. These fields include nephrology, pulmonology, cardiology, neurology, orthopedics, sports medicine, radiology, psychiatry – it really runs the gamut. They even interact with neonatology for babies born to women with lupus. So they also get involved with newborn babies.

[24:28] What He Wished He Knew Before Going into Pediatric Rheumatology

What surprised Bryce about Rheumatology is the pace of new discovery of new diseases and new therapies. He finds that it keeps on becoming intellectually stimulating and it doesn’t stop.

[25:33] Final Words of Wisdom

Finally, he wishes to tell those who might be interested in this field to find a pediatric rheumatologist. If you don’t know one already, or if you’re thinking about it, find one and reach out to them.

If you reach out to a pediatric rheumatologist and tell them you’re interested in the field, Bryce says they will bend over backwards to introduce you to the field and nurture you along. Just make that initial contact.