About a year ago, I stuffed all my earthly belongings into my black Volkswagen Jetta and set out on a 10-hour interstate journey. I had just graduated from residency at the University of Kentucky and was headed westward, to Iowa City, for a fresh start as a rheumatology fellow. During the 10 hours I spent on the road, my thoughts drifted from time to time to all the opportunities and challenges that lay ahead of me.
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Explore This IssueAugust 2015
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In my naiveté, I thought that things would be pretty much the same, only a bit busier and more focused on autoimmune and joint diseases. But it wasn’t long after I finished unstuffing my car that I learned I was thoroughly mistaken.
Fellowship is more than just a continuation of residency. It’s as drastic a change as the transition from medical school to internship. And although the lessons from prior training are applicable, to be a competent fellow, you have to build upon your previous strengths and be even more willing to adapt to changing situations. Of course, the experiences of each rheumatology fellow are unique, as are the characteristics of each training program, but there are seven lessons I learned in my first year that other new rheumatology fellows could probably benefit from.
- Take extra steps to be social, because fellowship is much more isolating than residency. It doesn’t take keen observation skills to recognize that most rheumatology fellowship programs are fairly small. Most institutions have only a few fellows in training at any given time, and the number of faculty physicians is not much greater. Contrast this to most internal medicine (and pediatrics) residency programs, where residents can be counted by the dozen, and there is a wide variety of physicians, between ambulatory care physicians, hospitalists, specialists and administrators. Although it doesn’t seem like it should make much of a difference, having so few people in a program alters the dynamics of training significantly and makes fellowship much more isolating than you would expect. Relationships are far more longitudinal and, out of necessity, deeper. Additionally, because there aren’t many concrete rotations in which you can take a break from interacting with the few people in your department, you have to make a greater effort to expand your social circle than just showing up to work.
- Don’t expect much scholarly or research activity in your first year. Starting fellowship is a lot like starting internship. You’re thrown into an entirely new situation, especially if you’re switching to a different institution. You’re squarely outside of your comfort zone and learning not only a new field of medicine, but also the basics of doing everyday things, like writing notes or understanding the workflow in the clinic. Believe it or not, that accommodation process takes a long time and drains your brain power. Although scholarly activity is feasible, especially relatively small endeavors like case reports, initiating larger research projects is out of the question, unless you are exceptionally talented at multitasking or are in a training program geared heavily toward research. Hopefully, the second year can provide more opportunities for scholarly activity, if that is your interest.
- Try to glean value from every patient encounter. There’s scarcely a rheumatology fellow alive who appreciates a consult for gout or fibromyalgia. But while we may gnash our teeth when we’re on the phone with the consulting physician, it’s important to recall that every clinical encounter has a purpose. I have found that even with conditions that can be easily dismissed and do not, for the most part, require specialist expertise—osteoarthritis or fibromyalgia, for example—there is always something worthwhile we can take away from the encounter. Whether it is in discovering a unique contributor to a disease process, honing the approach toward a difficult patient with chronic pain or just talking to a fascinating person who happens to be a patient, there still remains some value. If you curse your luck that you aren’t seeing interesting cases, then you’ll end up missing a lot of learning opportunities.
- Learn how to triage patients efficiently. Despite the fact that there is value in every patient encounter, not all encounters are equally valuable. For the new fellow, the ability to triage cases is a valuable skill that needs to be cultivated early. Even though our knowledge of rheumatology is still embryonic, it’s critical to understand when to dig deeply into the history and physical examination, and when to establish a diagnosis early in the encounter and simply move on. Inevitably, you will encounter attending physicians who are meticulous with every patient and demand the most picayune details. They can afford to be so detailed, but when you are operating on limited time to overcome a steep learning curve, you simply cannot waste time on feckless fishing expeditions during otherwise unremarkable clinical encounters.
- You can’t afford to lose your internal medicine (or pediatrics) knowledge. This may be the most controversial point on the list, but I feel that it is appropriate. You should expect your attending physicians to be well versed in rheumatology and clinical immunology—after all, they have been practicing it for years. But you can forgive them for not knowing the particulars of treating heart disease, diabetes or GERD. While your memories of residency are still quite fresh, theirs are slightly more remote; additionally, it is likely that they have not kept up with the latest updates. Because a critical part of rheumatology is to rule out other, nonrheumatologic diseases, this is where your presence is essential to providing optimal care for patients.
- You are not anyone’s scribe or physician assistant—and never will be. Naturally, when you are adapting to a new situation, you have to master the most basic challenges. I found that in my first few weeks, I really was not acting as a physician, but more as a stenographer who was recording what my attending physician was saying. Fortunately, I feel like I eased out of that role and assumed more control. But there is a very strong tendency to stay in that position more permanently. After all, it’s easier to be a yes-man and keep your supervisors happy than to be more engaging and risk offending them.
- Maintain balance between your commitments at work and at home. The most important, if not generic, piece of advice is to keep your work separate from your personal life. Fellowship, like residency, can be all encompassing. Whether you are on call or not, there is always work to do—whether it is writing notes, calling patients, preparing for presentations, or just reading up on diseases—and these tasks frequently spill over into your personal free time. However, it is imperative that you keep work in its proper context. Fellowship is only one part of your life, and you are undertaking extra training not just for the heck of it, but so that you, and the ones you care about, can live a better life. I would especially caution new trainees on accessing the electronic medical record remotely at home. Although it seems like a brilliant idea, it erodes those necessary boundaries between work and home.
Of course, it’s worth stating again that every rheumatology fellow and every training program is unique. For some, none of the above is applicable; for others, all are instantly relatable. Regardless, rheumatology fellowship for me has been, thus far, very enjoyable. There are innumerable obstacles, but surmounting them brings a great sense of satisfaction. Undoubtedly, helping patients recover their functionality and esteem is something I would never give up. The 10-hour cross-country car ride may have concluded 13 months ago, but the journey continues—thankfully with no end in sight.
Bharat Kumar, MD, is a second-year fellow at the University of Iowa pursuing a dual certification pathway in rheumatology and allergy/immunology. Dr. Kumar has a special interest in medical education, journalism and ethics.