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Reflecting on 15 years as  a rheumatologist

Reflecting on 15 years as  a rheumatologist

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I've taken on a role as an editor for a publication called Rheumatology Republic, an offshoot of The Medical Republic. The inaugural issue of Rheumatology Republic launched at the start of this month.

Here, I reproduce the piece I wrote for it.

Rheumatology is a journey, not a destination

February 2004. That's when I escaped the confines of hospital to set up private practice as a rheumatologist. There was a mixture of fear and excitement.  I was unknown among potential referrers and unloved at that stage. I saw 2 or 3 patients that entire 1st week. My start was slow but it allowed time to learn a raft of skills to develop as a private practice rheumatologist.

Now, in my 15th year in practice, this publication gives me an excuse to reflect. 

The following are a few personal observations, noting that I practise in a well-resourced, metropolitan environment.

Hospital training just does not prepare you for private rheumatology practice

Hospital-based rheumatology with sicker patients on the wards and under-resourced, busy outpatient clinics with excessive waiting lists did not ready me for the type of rheumatology I would see in private practice. 

As those of you rheumatologists based in the community know, the people coming to private rooms are different, the expectations are different, the pathology presented is different.

Unfortunately, I am not aware of any sustained progress made in training our future rheumatologists in the private sector. 

When freshly-minted rheumatologists join our practice, it’s very clear they need help adjusting to the new settings and the different types of problems they have to manage. It’s also very clear that most really have little experience in managing soft tissue rheumatism and the many problems caused by poor biomechanics and movement patterns. Few have the experience or tools to effectively deal with the regular presentations of chronic pain.

This of course matters. Especially when we are trying to care for people, aiming to help them understand their problems and finding ways to reduce the loss of productivity and the negative social impact of their rheumatic disease.

Surely, rheumatology training needs to be broadened.

In addition, my entire medical training did not include any teaching about small business. Given the vast majority of rheumatology is practiced out in the community in Australia, learning to run a viable, small business is vital for the rheumatologist’s peace of mind and efficiency. Fortunately, things have changed in this space. There are financial firms and private practice educators helping to bridge this knowledge gap.

Private practice rheumatology can be invigorating

As a registrar, I was told by senior colleagues how private practice can be isolating and over time, the drudgery of attending to patient complaints and problems day-in and day-out can be draining.

This can of course be managed, in some settings better than others. 

The traditional model of rheumatology practice with one consultant, 1-2 consulting rooms, a little waiting room and 1-2 administrative staff may follow that script. However, there is a shift to a few consultants working together with all the benefits that brings. Gen X and Gen Y rheumatologists are unlikely to be working the same number of weekly sessions, so group practice makes sense.

I’m lucky enough to work in a collaborative group practice with enthusiastic rheumatology colleagues and many rheumatology-aligned allied health colleagues. We teach and we learn from each other. We hold educational meetings, run preceptorships, mentor, provide cover for each other and share. 

The scope of my practice has shrunk

The longer I've been in rheumatology practice, the more general physician skills I've lost. For example, I have not prescribed an anti-hypertensive for blood pressure since I left hospital. This is generally the GP's domain and I have avoided stepping on any toes. Working in a city practice, there are also lots of other specialists, all tending to look after their own part of the body.

The mix of patients I see is also more limited. I definitely don’t get to see acute vasculitis very often, or sick lupus patients with threatened internal organs. They get referred to the hospital. Phew!

I tend to see people my age or younger with spondyloarthritis and rheumatoid. Lately, there’s been a run of 2nd and 3rd opinions, which is harder work.  Come to think of it, there’s also been quite a few diagnoses of fibromyalgia and chronic pain secondary to really poor biomechanics. 

As I tend to blog about inflammatory arthritides and as I’ve been involved in a number of awareness initiatives, I’ve had the good fortune to engage in-person and on-line with patients and rheumatology colleagues on these issues. This increased exposure allows me to learn from people far more expert than I am. People living with these chronic diseases require regular follow-up and over the years, they’ve filled up a larger and larger percentage of my available appointments. I’ve completed my 10,000 hours in these areas and have some insight and expertise in the clinical management of these. And that’s good for the ego and my professional development.

Again, I’ve worked out that I don’t mind a limited scope of practice. I do enjoy thinking of ways to improve the experience and health journey for the people who consult me, both while they are in my consultation room, and increasingly, even in the time between in-room consultations.

The rise of the Patient

During my training, I would never have guessed that I would have utilised the internet for rheumatology practice. Twitter and Facebook didn't even exist. 

In 2010, I started to dabble with social media, starting a blog. Through this, I've been exposed to a range of patients' comments. Some of this has been eye-opening and it has made me far more aware of what those who have chronic rheumatic disease experience: uncertainty, frustration, various side effects, misunderstanding, and also importantly, hope.

When we truly try to place the patient in the centre of what we are doing, rheumatologists can very much provide that hope. There are so many ways we can engage to improve awareness and to educate. 

I’m not just talking about an on-line presence.

Many of you understand the need for thoughtful design of our consultations, our workplace, and the supports we build for those who need our care.

As our treatments become more potent, rheumatologists need to raise their profile

In 2004, a few months into my 1st year, PBS-subsidised biologic DMARD therapy became available for rheumatologists to prescribe. We now have access to an increasing armamentarium to treat inflammatory disease. You know there has been quite an explosion of knowledge and scientific trial data in the last two decades with more to come.

Rheumatologists have become more useful to their patients (at least a cohort of them), and it is imperative that our traditionally low profile improves. 

If general practitioners and the general public don't even know what a rheumatologist is, and what we can do, how will people with the rheumatic conditions we treat well, ever come in contact with us?

It’s great to keep highlighting the “window of opportunity”, but what measures are we taking to remove the range of blocks affecting this, such as: 

  • the time for a person in the community to attend a GP or an allied health professional (AHP),
  • the flow of knowledge to help our GP and AHP colleagues recognise the potentially vague, early presentations,
  • the pathway for GP and AHP colleagues to access rheumatologists in different parts of this country,
  • the waiting times and costs to access rheumatologists?

There are not easy answers of course. I however think that raising the profile of rheumatology would point us in the right direction.

To date, I’ve not regretted the decision to be a rheumatologist. My professional career has been fulfilling and varied. I’ve had to learn a far broader set of life skills in developing the practice I want to work at. 

I’m still excited about our specialty and the difference rheumatologists can make, and hope to continue to harness this feeling to explore all the various things brewing and sprouting in my head.

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