Career: Getting patients back on their feet

A career in the rapidly evolving specialty of rheumatology offers doctors many exciting opportunities

RHEUMATOLOGISTS are doctors who investigate, diagnose, manage and rehabilitate patients with disorders of the musculoskeletal system.

This diverse range of more than 200 conditions includes arthritis, inflammatory spinal disorders such as ankylosing spondylitis, and multisystem autoimmune rheumatic disorders such as lupus, myositis, and systemic vasculitis. Rheumatologists are also trained in recognition and management of the breadth of regional musculoskeletal conditions including tendinopathies and osteoarthritis, as well as metabolic bone disease.

Rheumatology requires interdisciplinary knowledge and awareness of new developments in internal medicine, immunology, orthopaedics, neurology/pain management, rehabilitation, psychiatry, nursing and professions allied to medicine. Rheumatologists practising in adult medicine must also have knowledge of childhood and adolescent rheumatological disease to facilitate an effective transition to adult care.

Many rheumatologists practise the specialty exclusively but there are opportunities to subspecialise in a variety of areas such as rehabilitation or sports medicine. Rheumatology is a very research-active specialty, and in recent years a great many novel treatments have been developed, trialled and introduced across the range of rheumatic disorders.

Entry and training

Following successful completion of foundation training, doctors must undertake two or three years of core training before sitting the membership exam of the Royal College of Physicians (MRCP UK). This is then followed by a further four years of specialty training, as well as completion of the specialty certificate examination (SCE) in rheumatology. Increasingly, rheumatology training is being offered in conjunction with the opportunity to train for a dual certificate of completion of training (CCT) with general internal medicine.

The job

Most patients are treated in an outpatient department, but many also need to attend day treatment units to be administered novel biologic treatments by infusion. “Shared care” arrangements are increasingly common, where specialists and GPs, and homecare nursing teams jointly look after people with conditions such as inflammatory arthritis. Practical skills, including a range of joint and soft-tissue injections and increasingly ultrasound assessment, are invaluable to the rheumatologist.

As this specialty looks after patients with long-term conditions, there is a considerable amount of administration and liaison with the multidisciplinary team and other agencies. In most areas, there is active participation in continuing medical education, audit and research.

As a consultant, on-call and shift work in rheumatology is usually relatively light, although rheumatologists may contribute to the general medical on-call rota.

The British Society for Rheumatology (BSR) is the UK’s leading specialist medical society for rheumatology and musculoskeletal professionals. Membership provides access to a range of courses, eLearning and conferences as well as other advice and support.

Dr Elizabeth ReillyQ&A – Dr Elizabeth Reilly, clinical research fellow in rheumatology and chair of the BSR Trainees Committee, based in Bath

What attracted you to a career in rheumatology?

During my foundation years, I spent some time within rheumatology clinics and quickly realised that this specialty had what I was looking for – to develop a specialist interest whilst also maintaining my general medical skills given the multi-system nature of many rheumatological conditions. I also knew that I wanted to spend time in research, and the opportunities for this are plentiful.

What do you enjoy most about the job?

It has shown me what being part of a true multidisciplinary team (MDT) can achieve. Each team member has a clear and vital role within a patient’s care pathway. I also really enjoy the dynamic that is built up with long-term care patients, when you see their disease and quality of life optimised.

Are there any downsides?

Biological medications have become central to the management of some rheumatological diseases but funding can sometimes be tricky to secure, particularly in unusual or atypical cases. This may require an individual funding request to the CCG. When these requests are not approved, it can be a frustrating time for patients, families and clinicians.

What do you find most challenging?

Balancing the time spent in general medical on-call commitments with sufficient exposure to specialist learning opportunities or procedures can feel a challenge during training. It is important to be organised in knowing when specialist events such as clinics are occurring so that your time is used effectively.

What is your most memorable experience so far?

Last autumn I was asked to present at a large European specialist ankylosing spondylitis conference. The meeting was held in the opera house in the beautiful city of Ghent, Belgium. Stepping out onto that stage was really quite a daunting experience. However, the satisfaction of having succeeded in presenting without any nightmare complications really boosts confidence for future speaking events.

What are the most common misconceptions about the specialty?

Of all of the medical specialties, I think rheumatology is probably one of the least well understood. The vast array of clinical conditions which we look after does surprise some people. The potential for true medical emergencies in our patients can also be a bit of a shock.

Describe a typical working week.

I’m predominantly research-based, but during my training a standard week would comprise five outpatient clinics. These would be a mixture of clinics including general rheumatology, ankylosing spondylitis, connective tissue disease and SLE, early inflammatory arthritis, osteoporosis and joint injection clinic. I would also undertake a musculoskeletal ultrasound clinic every two weeks, report on DEXA bone density scans, and cover ward referrals as part of the rotation. Each week would also comprise a radiology MDT, followed by the postgraduate meeting offering regular opportunities to present clinical cases or as part of a journal club, and hear visiting lecturers.

What are the tools that you can’t live without in your day-to-day work?

There are multiple apps available to help calculate outcome measures for many rheumatological conditions. In my area of interest, axial spondyloarthritis, it is essential to have a tape measure and goniometer in clinic to accurately measure patients’ range of spinal movement (the BASMI score). Electronic devices such as iWatches or FitBits are also helping us to track patients’ levels of physical activity, pain, fatigue or sleep.

What opportunities are there for working in rheumatology?

Each hospital trust will have a rheumatology team who can explain how the service runs in your local hospital. They may have opportunities to get involved in audit, quality improvement projects or grand rounds. Taster days, particularly during FY1/2, can also be really useful. Rheumatology is a research-rich specialty, so if you are interested in pursuing this do speak to your local team or the British Society for Rheumatology (BSR), who have a mentoring scheme for young researchers.

Is there any advice you could give to a trainee doctor considering a career in rheumatology?

I would suggest exposing yourself to the specialty as early as you can and speaking to as many rheumatologists as possible because career paths can be hugely varied. The BSR events such as the new 21st Century Rheumatologist course, offer an introduction to the specialty for those at any stage of their medical career. The BSR website is also being updated with more information and we plan to have a greater presence at careers events across the country to answer questions. The annual BSR conference is also a great source of information and resources.

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