Perspective
Job Security
A rheumatologist makes the case for a career in her specialty.
By Hollis Krug, M.D.
As a rheumatologist, I am blessed with job security. I say this for reasons ranging from the medical to the economic, demographic, and even geopolitical. One reason I am confident my job is secure is the fact that I work for the Department of Veteran’s Affairs. With two wars going on, VA hospitals are busy places. Although the young men in their 20s with traumatic injuries may not be keeping me busy today, they will 15 years from now. Their older brothers and sisters, rousted from their reservist jobs to become active-duty military, are a different story. These soldiers, most of whom are in their late 30s and 40s, return home with lots of aches and pains accounted for by their age and amplified by the musculoskeletal trauma and overuse they experienced overseas as well as by PTSD, depression, and other psychological injuries they sustained. Personally, I find identifying and treating the causes of pain and disability in these returning veterans very rewarding.
I am also confident that my job is secure because the population is getting older. The aging baby boomers are an almost endless supply of patients who don’t want to succumb to their bodies’ limits. Baby boomers, after all, are a generation used to getting what they want. And what they want is their youth. Previous generations might have tolerated sore shoulders from worn rotator cuffs or painful knees from old football injuries or physically demanding jobs; but the baby boomers are unwilling to give up their view of themselves as healthy and fit. This is ironic because many baby boomers are anything but fit. Obesity is epidemic, and a lack of fitness actually contributes to the development of degenerative joint disease and disability. But because this generation is more familiar with modern medicine than any previous generation, they have faith that we providers can solve any problem they bring to us.
Another reason why I am confident my job is secure is the anticipated shortage of rheumatologists. The most recent workforce study from the American College of Rheumatology published in May of 2006 estimates that by the year 2025 the United States will need nearly 2,600 rheumatologists more than will be practicing—a 35% deficit. Training programs could theoretically expand to fill this need, but the anticipated rheumatology workforce shortage will likely affect academic institutions as much or more so than others. Thus, there may not be enough faculty to train new rheumatologists at a time when they will be needed most.
Between 2005 and 2025, the number of people between 65 and 84 years of age is projected to increase by nearly 70 percent. And the very elderly, those 85 or older, will increase by more than 60 percent. Individuals in these age groups are much more likely than their younger counterparts to suffer from osteoarthritis. According to the Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health, half of adults now report some form of arthritis or chronic joint pain. The CDC projects that percentage will increase as the population as a whole grows older.
During this same time period, many established rheumatologists likely will retire. These rheumatologists, trained during a time when the subspecialty was expanding, formed a mini baby boom within the profession. Even though declining supply and increasing demand may prompt some to continue practicing longer than they intended, a net loss is expected unless training programs produce more rheumatologists than they do now.
My job security also is a product of the culture of medicine these days. Most rheumatologic diagnoses are still based on findings gleaned from an expert clinical examination. For many medical students, who are being educated at a time when increasingly sophisticated high-tech diagnostic equipment can reveal what previously couldn’t be seen, physical diagnosis has lost its charm. Many rheumatologic conditions cannot be diagnosed with laboratory tests or imaging equipment. Performing a joint exam to determine the presence or absence of synovitis or other articular pathology in a patient with joint pain or stiffness seems much less important to medical students in their first exposure to clinical medicine than learning to interpret an MRI and much less sexy than analyzing a 3-D image of a beating heart. Consequently, it is not always easy to find medical school graduates who are interested in rheumatology.
In addition, most internal medicine residents don’t spend any elective time learning rheumatology. The few who do often take a vacation or interview for jobs or fellowships during the outpatient rotation. Yes, we know you call it a “rheumaholiday.” Rotations are usually only four weeks long, arguably too short a time to perfect a skill that requires learned touch to recognize subtle changes of inflammation. In fact, rheumatology trainees take months to perfect their ability to detect subtle synovitis in the small, easily accessible joints of the hands. A complex joint like the shoulder takes years to figure out. Therefore, it is a rare general internist or family physician who can detect early rheumatoid arthritis in the joints of a young, otherwise healthy, person or the hallmarks of inflammatory back pain in a 20-year-old with undiagnosed spondylitis, or who can recognize the constellation of symptoms that make the diagnosis of systemic lupus erythematosis. Orthopedists can examine joints, but they aren’t trained in treating autoimmune diseases. And the other medical subspecialists who are trained to treat autoimmune diseases such as nephrologists, allergists, and hematologists are not taught the skills required for physical diagnosis of musculoskeletal diseases.
A further deterrent to going into rheumatology has been the fact that reimbursement for our services has lagged behind that of other subspecialists, even though we are skilled in specialized physical diagnosis and treating complex illnesses with complicated therapies. This may be changing, as there has been a relatively greater increase in compensation between 1998 and 2002 for practicing rheumatologists compared with other subspecialists. Yet, academic rheumatologists have not seen such an increase. Although there is job security in rheumatology, that’s not the most important reason to become a rheumatologist. A better reason is the job satisfaction one gets from the practice. Rheumatologists develop long-term relationships with their patients, as chronic disease requires a long-term commitment on the part of both the patient and the physician. Twenty years ago, when a big part of the job was measuring, documenting, and attempting to ameliorate severe progressive deformity and disability, these relationships could be difficult. But with today’s new biologic therapies and higher rates of disease remission, we have the pleasure of seeing patients return with renewed abilities. Patients regularly return to say, “Thank you for giving me my life back.” That is heady stuff, even in this modern medical age.
There is another aspect of being a rheumatologist that I find even more rewarding: We touch our patients. In talking with trainees about the loss of diagnostic skills, I am invariably reminded of a teacher from my medical school days. He was an older physician who taught us to “always touch the patient.” This seems obvious; but in today’s fast-paced outpatient world, it is sometimes easy for other specialists to skip over the touch part of the exam. The rheumatologist, on the other hand, has no alternative to touching shoulders, pressing on spines, and holding patients’ hands. This physical interaction not only gives clues to a diagnosis, it also solidifies the bond between the giver and recipient of care. To me, it epitomizes the doctor-patient relationship.
Rheumatology does offer job security. More important, it offers job satisfaction. For the physician who wants to connect deeply with patients and use his or her intellectual and physical diagnostic skills, it’s an ideal choice. MM
Hollis Krug is an associate clinical professor at the University of Minnesota and a staff rheumatologist at the Minneapolis Veterans Affairs Medical Center.