As you are likely aware, you will need to do 2-3 years of IM (2 yrs via the ABIM research track pathway with guaranteed rheum fellowship after IM if you have considerable research and want to continue research as part of your career). Most rheum fellowship programs are 2 yrs with the more academic ones being 3 yrs. Rheumatology is an intellectually challenging field (ask many IM residents which is the hardest section on the in-training exam). There is a wealth of new knowledge in the immunologic basis of rheumatologic diseases. You should scan the table of contents of Arthritis and Rheumatism to see if the pathophysiology behind the diseases interests you and to get a sense of how complex the immunology is. The therapeutic armamentarium has grown tremendously as well. When I started med school over a decade ago, the textbooks talked about steroids, gold and maybe methotrexate. Today, in addition to steroids and MTX, there are several more general immunosuppresive agents as well as all sorts of monoclonal antibody therapies (against TNF, B cell targets, T cell targets, IL 1, IL 6) and small molecule inhibitors targeting various aspects of the immune system.
As far as what practice is like, it may be hard to get a sense from an inpatient rotation (as is the case with most internal medicine and its subspecialties) because rheumatology (like the vast majority of IM and its subspecialties) is a primarily outpatient discipline. Unfortunately, medicine (the whole field) is undergoing a change where the hospital and its conglomerate system is becoming the primary site of medical care with physicians becoming employees... This is a separate discussion, but one to be cognizant of in the years ahead, not just for IM but click to any other specialty forum here and you will begin to understand the ramifications of this. But why do I mention it? I would invite you to do a web search with the phrase "arthritis and osteoporosis center" and click on the websites of some private practice rheum groups and you will see the range of services provided by rheumatologists in outpatient private practice that you might not have been aware of by seeing rheum from only an inpatient/hospital perspective. These include:
- Joint injections for diagnosis and therapeutic injections with steroids and / or viscosupplementation
- Doing musculoskeletal ultrasound for routine diagnostic purposes in patients suspected of having inflammatory arthritis as well as to follow disease progression and response to therapy (rheumatologists can interpret their own U/S findings after appropriate training)
- Ultrasound guided injections of joints (including hips) and also ultrasound guided injection of trigger points for interventional pain management of patients with fibromyalgia
- Infusion center services (like those provided by med oncologists) for the new biologic agents and systemic chemotherapeutic immunosuppressants
- DEXA scanning for osteoporosis (after all, your patients will be on chronic steroids and many will be post-menopausal... Rheumatologists can be certified to read their own DEXA scan results after specific training)
- in house X ray and lab services are offered by some rheum practices as well.
The MSK physical exam is one that allows you to make a diagnosis that localized to a fairly well defined locus that can then be confirmed by imaging if need be. There are a host of maneuvers that specifically isolate parts of the neuromusculoskeletal system to help you narrow down and pinpoint the diagnosis. So if you like still being able to use your exam skills in this age of fancy tests and imaging, rheum and other specialties using the NMSK exam are a good choice.
Below, I have put together some salary data (because every student/resident always wants to know). As you can see 50% of surveyed rheumatologists made > 240K. On average, group practice pays more than hospital employment (probably because of the ability to do more of the above listed services without being limited by hospital delineation of privilege policies).
Median salary: $240,250 (4.89 percent increase from 2012)* AMGA 2013 data
Hospital-employed salary: $201,000* Medscape 2013 data
Multispecialty group practice salary: $224,000* Medscape
Hope this helps somewhat. Good luck with your choice whatever you choose. Just be informed and stick with what you enjoy. What was popular and high paying 10 years ago will not necessarily be the case in the next 10 years.
