The transition from being a rheumatology fellow to being in private practice is significant. As I reflect on the past two years, I want to share my observations and begin a conversation about how to prepare rheumatology fellows for careers as practicing rheumatologists. The difference between learning about rheumatology and practicing rheumatology is nuanced. Upon joining an independent private practice, I quickly discovered how much I had to learn about the practical aspects of caring for rheumatology patients. My fellowship taught me the science of rheumatology. I had the opportunity to treat many different diseases and saw a wide variety of both simple and complex cases, from gout to central nervous system vasculitis. By the end of my fellowship, I was comfortable practicing independently. I was quoting my favorite studies by journal, volume and issue with my co-fellows and attendings. I was well-versed in the literature and prepared for the board exam.
A seismic change occurred when I started my first job. Although I was very familiar with how to properly treat rheumatologic conditions, I found new challenges in patient management. Working through insurance companies and the complexities of pharmacy benefit managers were not entirely new, but suddenly became more complex. I had done many sample board questions, but none of those questions had ever addressed which insurance companies required a prior authorization for which medications. Nor did they address how your practice may be affected by the reimbursement for infusions vs. injections, buy-and-bill medications and visits, for example.
Additionally, leadership style changes on entering private practice as you become responsible for managing support staff. Things that do not need to be directly done by the physician can and should be assigned to other members of your team. This allows more time with the patient, which enhances quality of care. Training staff to anticipate and understand the support you need requires mentoring and is not an intuitive skill. (Editor’s note: Rules governing what medical assistants, LPNs, RNs and APRNs, and APs can do with patient care and EMR management vary by state, dictate patient workflow and practice management and are not taught in fellowship.)
Importantly, the patient population changes, as well. The number of patients seen in a day quickly increases. How will you space out these patients in your schedule? How will you move between rooms as you see multiple patients at the same time? Where will you be when a patient is working with the X-ray technician, phlebologists or, perhaps, the ultrasound technician? How will you answer patient messages during the day or communicate with referring physicians?
Having the opportunity to establish long-term relationships with patients is also a unique opportunity afforded by practicing rheumatology. Learning to communicate with patients to help them understand your approach to diagnosis and treatment of their illness is a skill that I have refined during my first two years.
I have learned that it is my job to prove that the patient doesn’t have an illness I can treat. Gaslighting is a major issue with certain patient populations. Once inflammatory disease is ruled out, an important part of the rheumatology consultation involves validating patients’ experiences within a medical model, directing the patients toward next steps in management and avoiding the sense of gaslighting that can result from negative autoimmune workups. A positive anti-nuclear antibody test with a negative workup can become an opportunity to engage a patient in conversation about healthy lifestyle choices instead of dismissing autoimmune disease in the patient.
Fellows who join hospital-based groups or enter academic medicine will face similar challenges. It would be worthwhile to create a curriculum and resources for fellows as they transition into the role of rheumatologist. Introduced by the ACR in 2022, The Training Rheum is targeted to nurse practitioners and physician assistants to guide the education necessary for rheumatology practice. A similar course, or online community, could be offered on the practicalities and art of rheumatology.
I still have much to learn about being a rheumatologist. The art of medicine cannot be fully grasped over the course of a fellowship, but with the right support it can continue to be developed. I have begun to appreciate that these two years have really been another fellowship where my coursework has been directed by patients, staff and colleagues that have helped me grow. I look forward to continuing to explore the ways my experiences can help others as they embark on the lifelong process of becoming a rheumatologist.
Tom Berry, DO, is a rheumatologist in his second year of private practice at Arnold Arthritis and Rheumatology, Skokie, Ill.
