Next gen physicians: Rheumatology fellows optimistic for ‘happier’ specialty

Many rheumatologists working today have navigated the specialty from the era of deeply flawed treatments like gold, through epoch-defining shifts brought on by biologics, biosimilars and, most recently, the unexpected crisis of COVID-19.

However, as the number of rheumatologists who practiced during the pre-methotrexate days dwindle due to retirement, a new generation of clinicians and researchers is set to take over, and they have a few things to say.

To gain a sense of what the future of rheumatology holds in the view of those in the earliest stages of their career, who will be tasked with shepherding the field into its next generation, Healio Rheumatology interviewed current residents and fellows within the specialty.

Perhaps the most striking aspect of the commentary offered by these early-career rheumatology providers was their optimism.

“The field is evolving faster than ever, and there is always cutting-edge research and knowledge to learn and incorporate into practice,” Brian Jaros, MD, a rheumatology fellow, PGY-5, at the Northwestern University Feinberg School of Medicine, in Chicago, said in an interview. “One of the most exciting parts of choosing a career in rheumatology is the speed of pharmacologic advancement within the field. It is astonishing. We are continually able to provide our patients with more options for treatment.”

These emerging voices in the field also already seem to understand the mystique that drew their predecessors to the specialty.

“As a resident, the rheumatologists that I got to work with always seemed to be the doctor’s doctor, serving as the consultant of last resort to help solve a challenging diagnostic dilemma,” Matthew Lempel, MD, a rheumatology fellow at Yale-New Haven Hospital, told Healio Rheumatology.

However, underlying this enthusiasm are some unnerving realities. The most obvious is the ongoing workforce shortage, which is expected to be exacerbated by an increasing rate of retirements.

“This trend is concerning and underscores the importance of addressing the growing demand for rheumatology services in the health care system,” Jennifer Elise Abdalla, MD, a rheumatology fellow, PGY-4, based in Cleveland, told Healio Rheumatology. “However, in terms of my own expectations for my career, I see this workforce shortage as both a challenge and an opportunity.”

With fewer professionals in the field, one of those opportunities is to make significant contributions in both patient care and research.

“It is comforting to hear that there likely will be high demand for our services,” Lempel said.

Meanwhile, the increasing corporatization of medicine, most recently represented by the growing presence of private equity firms, will be another factor most new rheumatologists must consider. The choice between working in a large health system vs. a small practice is a multifactorial equation, with salary, debt, autonomy and access to technology being just a few of the variables.

“The question of whether to work in a private practice or a health system has been weighing heavily on my mind,” Abdalla said. “I am still undecided on which path to pursue.”

Regardless of whether these young providers choose to work in a health system or a private practice, to focus on patient care or research, or to reside in a rural or more urban setting, one message pervades, loud and clear, throughout — the desire for a work-life balance that is actually balanced.

“Many of us recognize the importance of making time for our personal lives in order to maintain a sense of fulfillment and happiness,” Abdalla said. “I make a conscious effort to prioritize spending quality time with my loved ones, as they are the reason that I am where I am today.”

‘Energizing Young Trainees’

Much of the news surrounding the workforce shortage is rife with gloom and doom. Even at the outset of their careers, new providers are being forced to consider a diminished pool of colleagues as a factor in their career path.

“This is really unfortunate because it means we will be losing a lot of great mentors and patients will be having more difficulty accessing care,” Alexandre Matar, MD, a PGY-3 internal medicine resident — who recently applied to become a rheumatology fellow — at the MetroHealth System, in Ohio, said in an interview. “There will be pressure to see more patients in less time and it may be difficult to schedule timely follow ups.”

To overcome these hurdles, younger physicians — armed with their aforementioned enthusiasm and optimism — will have to “step up and fill the gap,” according to Abdalla.

“I am committed to contributing to the field of rheumatology, providing high-quality care to patients, and continuing to advance the field through research and innovation,” she said.

Beyond the contributions of individual providers like Abdalla, systemic solutions will be necessary to fill these gaps. In a 2020 paper published in Seminars in Arthritis and Rheumatism, Miloslavsky and Bolster wrote that expanded training of rheumatologists, increased use of advanced practice providers, more comprehensive reliance on telemedicine, and minimizing burnout among providers will be critical to alleviating the burdens of caring for a growing rheumatology patient population.

Jaros expressed a need to bring “excitement” about rheumatology to physician assistants and nurse practitioners, as well as a necessity among rheumatologists to see these providers as valued contributors to the workforce.

“We will continue to collaborate with these professionals more and more, particularly in light of the physician shortage,” he said. “In this vein, I expect that care within rheumatology will continue to become more of a team model — not just a physician and a patient, but also APPs, nurses, clinical pharmacists, ultrasonographers and more — in order to offload burden of care from solely the physician. Most importantly, this will improve patient care through a more holistic and comprehensive approach.”

Primary care will also play a critical role, according to Desh Nepal, MD, chief fellow in rheumatology at the Medical College of Wisconsin Affiliated Hospitals.

“Rheumatology has such a limited workforce that is seeing patients who could otherwise have been managed well by primary care providers,” he said in an interview. “This only makes the workforce shortage worse. Consequentially, a patient with a true rheumatological illness must wait months before being seen.”

Although organizations like the American College of Rheumatology and EULAR have targeted recruitment as a key platform for the future, drawing talent has long been a deficiency for the specialty.

“The educational system has a fundamental flaw regarding trainees’ exposure to rheumatological illness during residency training,” Nepal said. “The rheumatology field is so unknown to many primary care providers due to a lack of robust exposure during residency training.”

Mentorship and exposure were “major factors” that drew Jaros to rheumatology, he said.

One day, he hopes to return the favor.

“It is vital my colleagues and I provide this to the upcoming generation of physicians,” Jaros said. “A major cornerstone of addressing the workforce shortage is energizing young trainees about rheumatology.”

However, recruiting providers to rheumatology is just one more task in a labor pool that is already pushed to its limit. It is for this reason that work-life balance will be essential to maintaining enthusiasm and moving the specialty forward.

‘Be Fully Present in the Moment’

Much ink has been spilled about shifting trends in workplace habits in medicine. Older professionals gave everything to their careers, while the emerging workforce prioritizes their personal lives — or so it would seem.

The debate is not so simple, according to Matar.

“When the rules are more rigid, it is natural to prioritize work,” he said. “However, in recent times, increased opportunities for wellness within organizations has allowed more flexibility and for more individuals to find the right balance for them.

“Our personal and professional lives are interconnected,” Matar added. “Success in one translates into the other, and the reverse is true as well.”

Rather, the definition of success is personal, Matar argued. For some, success could mean working tirelessly to maximize income or achieve a childhood goal. For others, it could mean working fewer hours to make a space for their personal lives.

“It is important for each one of us to really understand what success means for us in each of these realms, to know which work-life balance is right for us,” Matar said. “That insight will allow us to achieve the best possible outcome for us and the workplace.”

According to Nepal, younger practitioners have begun to recognize that “work” and “life” need not be an either/or proposition.

“The key is to be fully present in the moment,” he said. “When at work, my focus is entirely on work, and when at home, I strive to leave work behind.”

This type of thinking can lead to better patient care, according to Jaros.

“As physicians, we have a commitment to our patients, and this often comes through in terms of time spent helping others,” he said. “Although this characteristic is crucial to our line of work, more and more we are recognizing that physicians can provide the best care when they, themselves, are well.

“My hope for my generation is that we continue to generate a conversation about what it means to succeed both professionally and personally without having to compromise either aspect of our lives,” Jaros added.

As the child of a practicing physician, Lempel said he understands and appreciates the mindset of previous generations who gave everything to their careers — and sacrificed almost everything else. However, he also encouraged his fellow trainees to recognize that a career in rheumatology may actually lend itself to a more level balance between work and non-work.

“First, there is a scarcity of true rheumatological emergencies,” Lempel said. “That makes it a field where one can find the right balance of professional success and satisfaction without sacrificing personal responsibilities or interests.”

Another benefit is that there are many different career paths one could take as a rheumatologist.

“From working in a basic science lab to serving as a consultant in the pharmaceutical industry, the opportunities are truly endless,” Lempel said.

Regardless of the path, however, it seems likely — based on sheer numbers — that many new rheumatology professionals will work in a corporatized setting. Understanding the pros and cons of corporate employment vs. a small practice, and how they fit with an individual providers’ personal values, will be critical to forging a fulfilling career.

Cross-specialty Collaboration vs. Independence

“The evolution of the health care system where ownership is predominantly held by large systems and private equity rather than individual physicians has played a greater role in shaping how young physicians prioritize their work-life balance,” Lempel said.

On the one hand, large health systems offer the benefit of taking care of the business aspect of practicing medicine, according to Matar.

“This will allow me to focus more on clinical work,” he said.

The complexity of the specialty also argues in favor of employment in a large health system, Matar added.

“Rheumatology is a multisystem specialty, and a lot of the time, patients present really sick,” he said. “It is important to be within a large health care organization where you can cooperate with experts from different specialties and have the resources to turn things around for patients.”

Indeed, it is this spirit of collaboration that brought Jaros to his specific choice of focus.

“This collaboration is one of the reasons I enjoy working in vasculitis so much,” he said.

However, there are other reasons that might compel a clinician to work in a larger facility, including the opportunities to offer mentorship.

“Beyond being a clinician, I love being a teacher,” Jaros said. “Larger health systems tend to have more built-in interaction with trainees who we can educate, mentor, and show just how awesome rheumatology is.”

Lempel, on the other hand, opted to join a private practice.

“The practice is comprised of several physicians with similar interests in a geographical area, which was desirable to me,” he said. “I have a particular interest in point-of-care musculoskeletal ultrasound and felt that this position would best allow me to continue to hone this skill and implement it in my daily practice.”

According to Lempel, independence is often the strongest argument in favor of private practice.

“Perhaps a good example highlighting the benefits and challenges of various employment situations is that unlike some discussions I had with large systems, in private practice it seems that I may have more autonomy in how I could build my own patient panel and care model,” he said.

Although the trend toward corporate systems may seem unavoidable for many young rheumatologists, there is still a choice regarding the location of employment. The needs of urban, suburban and rural patient populations are a consideration for many emerging clinicians.

‘Drawn to the Opportunities’

In a 2020 paper published in Current Opinions in Rheumatology, Lennep and colleagues aimed to assess disparities in rheumatology care between rural and urban areas. Their findings showed significant diagnostic delays in rural populations, and that these delays are likely to worsen given the impending workforce shortage.

Despite the critical need for more providers in rural areas, the young practitioners who spoke to Healio Rheumatology all suggested that they would prefer to work in an urban or suburban setting. The reasons they gave — both professional and personal — highlight the challenges involved in convincing physicians to forego larger population centers.

“Working in an urban setting allows one to care for a breadth of pathology while also considering social determinants of health and how they can affect a care plan,” Lempel said. “Suburban practices may be able to provide greater resources but often at the expense of a lesser multidisciplinary team.”

Jaros, meanwhile, stated that the wider variety of food and culture offered in urban areas is attractive for him as a young practitioner starting his career.

“Having spent nearly the past 10 years in New York City and Chicago, I find myself continually drawn towards big city living,” he said.

According to Abdalla, who was raised in a small rural town, this dynamic is likely to continue to be problematic for patients outside large cities and their suburban collar communities.

“Having grown up in rural south Mississippi, I have a deep appreciation for the sense of community and connection that small towns offer,” she said. “While I cherish the memories and values instilled in me from living in a rural area, I am drawn to the opportunities and diversity that urban settings present for both personal and professional growth.”

Beyond the dynamic environment and diverse patient population, the availability of specialized health care resources and the potential for collaboration with a wide range of health care professionals are additional draws that urban work environments offer.

As young trainees wrestle with the “where” of their future employment, they also must consider the “what.” The opportunity to take care of patients, conduct research or both is something every young rheumatologist will decide.

‘A Happier Specialty’

“Patient care is at the heart of why many of us choose to pursue a career in medicine,” Abdalla said. “The direct interaction with patients, the opportunity to make a positive impact on their health and well-being, and the ability to provide compassionate and personalized care, are incredibly fulfilling aspects of the profession.”

However, like many trainees, Abdalla also recognizes the importance of research.

“Patient care and research are intricately connected and essential to providing the best possible care for our patients,” she said. “Without research, we would not have the evidence-based practices and therapies that are vital in delivering high-quality care to our patients.”

It is in fact these research efforts — into future therapies and practices — that has Abdalla and Nepal so optimistic about rheumatology in the first place.

“I am super excited about the role of biologics in the current management of rheumatological illness,” Nepal said. “As I see it, we are in the iPhone 1 or 2 era of these biotechnologies. By the time we reach the iPhone 15 era, the implication in patient management will be even greater — possibly curative by then. More importantly, although it may have taken nearly 20 years for the iPhone to reach its current state post-debut, biotechnologies will develop in much less time, as artificial intelligence helps transform how medical research is done. This will likely happen over the next 3 to 5 years.”

Although Abdalla was not as specific in her predictions regarding the future of biologics, diagnostics and novel approaches like chimeric antigen receptor T-cell therapy, she stated that the field will likely change significantly in the course of her career, particularly in terms of personalized medicine.

“In light of recent exciting developments, my expectations for patient care in rheumatology are optimistic and transformative,” she said. “I anticipate that we will see a shift toward more personalized and precision medicine approaches, tailored to each patient’s specific disease characteristics and individual response to treatment.”

Abdalla added that she expects rheumatology to see “a paradigm shift towards more targeted, efficient, and curative treatments that enhance the quality of life for individuals living with these chronic conditions.”

“This will come as we continue to advance in our understanding of rheumatologic conditions and the mechanisms underlying them, I expect to see,” she said.

As therapies continue to evolve, the “chronic” part of these conditions may even become an anachronism, according to Matar.

“Rheumatology once was synonymous with debilitating disease and treatment was limited to pain control,” he said. “Recent advances have allowed many rheumatological conditions to become manageable chronic conditions, like diabetes.”

Matar argued that curative therapies — should they arrive in rheumatology — could transform the traditional long-term personal relationship that rheumatologists entertain with their patients to a shorter term one.

“The improved outcomes will make it a happier specialty,” he said.

• References:
• Jerome DC, Zhou AL. J Rheumatol. 2023;doi: 10.3899/jrheum.2023-0409.
• Lennep DS, et al. Curr Opin Rheumatol. 2020;doi:10.1097/BOR.0000000000000694.
• Miloslavsky EM, Bolster MB. Semin Arthritis Rheum. 2020;doi:10.1016/j.semarthrit.2020.05.009.

• For more information:
• Jennifer Elise Abdalla, MD, can be reached at 9500 Euclid Ave., Cleveland, Ohio 44195; email: abdallj4@ccf.org.
• Matthew Lempel, MD, can be reached at 333 Cedar St., New Haven, CT 06510; email: matthew.lempel@yale.edu; sean.mccabe@yale.edu.
• Brian Jaros, MD, can be reached at 420 E Superior St., Chicago, IL 6061; email: brian.jaros@nm.org.
• Alexandre Matar, MD, can be reached at 9500 Euclid Ave., Cleveland, Ohio 44195; email: amatar@metrohealth.org.
• Desh Nepal, MD, can be reached at 9200 W. Wisconsin Ave., Milwaukee, WI 53226; email: dnepal@mcw.edu.