Rheumatology

Rheumatology is a specialty in which patients of all ages are treated. Patients have a wide variety of acute and chronic musculoskeletal problems including rheumatoid arthritis, osteoarthritis, autoimmune rheumatic disease such as lupus (SLE), scleroderma and vasculitis and osteoporosis, metabolic bone disease, back pain, soft tissue problems and sports injuries. Rheumatology is a practical specialty that includes performing joint aspiration and injection, synovial fluid microscopy, soft tissue and joint ultrasound, epidural injections, nerve root blocks and nerve conduction studies. Doctors in this area liaise closely with primary care doctors, orthopaedic surgeons, and the multidisciplinary team that includes nurses, physiotherapists, occupational therapists and podiatrists. Rheumatology can be practised as a single specialty or in combination with general medicine (GIM).

The realities of rheumatology

The common perception is that rheumatology is predominantly an outpatient-based specialty. This is largely true but rheumatologists have a remit that varies depending on the units and the nature of their posts. The patients coming to clinic cover a wide variety of diseases, ranging from common conditions such as osteoarthritis, osteoporosis and back pain to more complex patients with, for example, vasculitis and lupus nephritis who require close monitoring by a number of specialists (eg renal and chest physicians). The ability to work with other therapists and clinicians and to get to know your patients well over time is very rewarding. Seeing patients respond to treatment interventions provided at many levels by multidisciplinary care shows the benefits of teamwork. Since you do get to know your patients well over time, it can be challenging to manage patients whose response to certain treatments may diminish with time. Finding treatments that suit them and to address the psychosocial issues this can create is a challenge that most rheumatologists face in their work.

Getting into rheumatology

It is important to acquire hands-on experience in rheumatology during your training. The best way to do this is to apply for a foundation programme that includes rheumatology. Other posts are ‘stand alone’ and can be applied for after completing your initial training. These posts usually require MRCP (Part 1). It is also a good idea to introduce yourself to the rheumatology team in your hospital. Arrange to sit in on clinics if possible. This will help you to gain experience hands on. The Royal College of Physicians has regional specialty advisors for each medical specialty. It may be able to help put you in touch with helpful contacts.

Key skills and aptitudes

Rheumatology allows a great opportunity to practise clinical medicine in its broadest sense. Rheumatic diseases such as SLE, vasculitis and rheumatoid arthritis can affect many body systems and so a good grounding in clinical medicine is essential. A good knowledge of immunology is important as this forms the basis to understanding the pathology of many rheumatic diseases and the rationale for biological therapies. During medical school, training programmes will include exposure to orthopaedics and rheumatology. If you find the subject interesting, it may be worthwhile undertaking a BSc in a rheumatology-related discipline such as immunology. A person with good communication and diagnostic skills makes a good rheumatologist. Having empathy, patience and the ability to deal with complex psychosocial issues is important. It is vital to have an aptitude for clinical procedures and to be able to work in a team. An individual who can apply knowledge in anatomy and immunology is likely to enjoy this specialty. There are also opportunities to develop a subspecialty interest and combine this with research or GIM. There are good opportunities for flexible training in rheumatology and the on-call duties are manageable.

Nidhi Sofat is a specialist registrar and Wellcome Trust research training fellow at The Kennedy Institute of Rheumatology, Charing Cross Hospital Campus, Imperial College London.