Dual certification is neither a conventional nor a low-stress career path in medicine. But choosing to train in specialties complementary to rheumatology, such as pulmonary/critical care or allergy/immunology, can offer more expansive career and research opportunities. This career choice can lead to a better understanding of complex disease, and the ability to better care for patients with complicated conditions.
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Explore This IssueJuly 2022
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For Bharat Kumar, MD, MME, FACP, RhMSUS, associate program director of the Rheumatology Fellowship Program and clinical assistant professor in the Department of Medicine at the University of Iowa, Iowa City, the decision to pursue a fellowship combining rheumatology and allergy/immunology appeared to offer a more satisfying career than pursuing a single specialization. His interest in dual certification arose during his residency at the University of Kentucky, Lexington, where he encountered patients whose underlying immunodeficiencies, such as autoimmune lymphoproliferative syndrome and autoimmune polyendocrine syndrome, “really triggered my interest in this overlap between rheumatological and clinical immunology.” Writing in The Rheumatologist in 2019 about his career choice, he noted that his more expansive knowledge base as a dual-boarded clinician can sometimes lead to more streamlined coordination of care, especially when looking at overlapping diseases (see “Dual Certification: Is 1 Head Better Than 2?”).1
Dr. Kumar’s article is not the only time The Rheumatologist has covered this topic. For an article in 2015 on dual certification, we interviewed Paul F. Dellaripa, MD, co-director of the Interstitial Lung Disease Clinic and associate professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, Boston, and Vladimir N. Despotovic, MD, assistant professor of medicine at Washington University in St. Louis.2
For this revisit, we spoke with four physicians who reflected on factors that contributed to their career choices. Completing their dual training has often required work and time, as well as ingenuity and persuasiveness with program directors at their institutions.
The Pull to the Path
Jason H. Melehani, MD, PhD, a rheumatology and pulmonary medicine fellow in the Translational Investigator Program at Stanford University School of Medicine, Palo Alto, Calif., entered medical school thinking he would specialize in pulmonary/critical care. He completed his medical and graduate research training at the University of North Carolina, Chapel Hill, earning both a medical degree and a doctorate in pharmacology. In his dissertation research, Dr. Melehani studied the molecular mechanism by which the innate immune system and Staphylococcus aureus interact.
During his internal medicine training, his interest in rheumatology grew out of his experience caring for patients with lupus, mixed connective tissue disease, myositis and other autoimmune conditions. That’s when he decided to add rheumatology into his fellowship training and worked with Stanford to create a first-of-its-kind combined training program in rheumatology and pulmonary medicine.
Dr. Melehani continues to fuel his interest in immune-mediated pathogenesis in lung disease. His work currently focuses on studying how Sjögren’s syndrome contributes to lung disease and lung transplant outcomes in patients with systemic sclerosis and other connective tissue diseases.
Erin Wilfong, MD, PhD, instructor in the Department of Medicine at Vanderbilt University Medical Center, Nashville, Tenn., went into residency at Johns Hopkins University, Baltimore, knowing she was going to be a rheumatologist. Her time in medical school at Duke University, Durham, N.C., had exposed her to complicated rheumatic patients, and during residency, she realized how much she loved caring for critically ill patients. That’s when Dr. Wilfong realized that she “loved the acuity” of the intensive care setting. “I loved the adrenaline rush,” she admits. She also realized that caring for critically ill rheumatic patients, including those with catastrophic antiphospholipid syndrome, systemic lupus erythematosus and granulomatosis with polyangiitis, was her true passion.
Big P, Little r
Kristin Highland, MD, of Cleveland Clinic, Ohio, is fellowship trained in both pulmonary/critical care and rheumatology. “I call myself a ‘big P, little r,” she says, because she first trained to be a pulmonologist at the Medical University of South Carolina (MUSC), Charleston. Her attraction to rheumatology, she notes, was partly due to “being in the right place at the right time” because rheumatology and pulmonology shared clinic space at MUSC.
Although she began her career in pulmonary critical care, she inherited from her mentor a shared interest in interstitial lung disease (ILD) and pulmonary hypertension, which are both complications common in connective tissue disease. “Although I’m really more of a pulmonologist, I thought that if I studied rheumatology, I would be better at taking care of rheumatologic patients with ILD and pulmonary hypertension because I would better understand the pathobiology,” she says.
She joined the faculty in pulmonary critical care and, thanks to a supportive supervisor, was able to then begin her rheumatology fellowship part time. As a result, her fellowship training took a bit longer to complete.
By the time Dr. Wilfong finished residency at Johns Hopkins, she was clear about her preference for the intensive care setting. “I was not able to imagine a career where I did not do critical care medicine,” she says. Mentors at Johns Hopkins urged her to obtain certification in pulmonary/critical care while she embarked upon her rheumatology fellowship. “When I applied for fellowship, I was very up front that this was something I wanted to do.”
Convincing program directors that this was her course took some doing, she recalls. For example, University of California, San Francisco Fellowship Program Director and Rheumatology Division Chief David Daikh, MD, “struggled at times to understand why I was doing this,” she says. But on one occasion Dr. Daikh was present when she was moonlighting as an intensivist at the San Francisco Veterans Affairs Medical Center. Dr. Wilfong coded a patient and then resuscitated him, and when she left the intensive care unit (ICU) after that, she found Dr. Daikh waiting for her. “This is what you are,” he told her.
“At my core, I’m an intensivist who happens to love rheumatology patients,” Dr. Wilfong asserts. She says she “brings a lot to the table” with critically ill rheumatic disease patients. “I can really help manage them because I understand both worlds. I had to do both trainings because I wanted to be an ICU attending.”
The Research Angle
During his time in graduate and medical school, Dr. Melehani developed an interest in drug development—“understanding the evidence supporting our use of medications in the clinic”—as well as in the process of discovering new targets and creating new medicines. To better understand this process, Dr. Melehani worked as a fellow at Hatteras Venture Partners, a healthcare- and biotechnology-focused venture capital firm in North Carolina. At Hatteras, Dr. Melehani worked closely with the investment team and managing partners to evaluate early-stage therapeutic development companies to find those with the greatest potential for transforming medicine.
Dr. Melehani believes acquiring dual certification will position him in a unique way should he gravitate toward drug development. “I’m interested in immune-modulating therapies, and I think that it’s very likely that I’ll end up working in a biotech or pharmaceutical company on the drug development side,” he says. Many companies, he notes, organize their research and clinical teams by combining rheumatology and pulmonary medicine, often under the umbrella of inflammatory and immune-mediated diseases.
A Trend or Not?
The University of Iowa is supportive of dual-certification fellowships, says Dr. Kumar, and the department currently does have a dual-certification fellow in training. “There’s a long history of collaboration between allergy/immunology and rheumatology here. There is a lot of championship for innovation.” However, he notes, academics tends to prioritize specialization in one specific aspect of a disease or entity. The expectation for those pursuing an academic career may be that they will become an expert in that one disease.
Dr. Kumar says dual-certified rheumatologists and allergists/immunologists “can find homes within academic medicine by investigating niches in diseases that straddle both specialties or with cross-application of a competency from one field to another (like the novel use of DMARDs [disease-modifying anti-rheumatic drugs] for immunologic diseases).”
“I wish it [dual certification] would be a new fad that would take off,” says Dr. Highland. “I could use some partners!” She remains appreciative of the additional effort it took to acquire dual certification: “It has heightened my awareness for looking for these types of patients who have idiopathic lung disease, because connective tissue diseases can be somewhat subtle.” She contends that dual certification is an academic career “with definite job security.”
Dr. Kumar adds, “I think there is movement towards synergistic pathways, but there are too few of us to say whether something is becoming a trend.”
Among the dual-boarded rheumatologists with whom we spoke, most know or know of the others. They enthusiastically embrace their career choices. “When I reflect on what gives me joy in my career,” says Dr. Wilfong, “I realize that my favorite patients to take care of, even to this day, are critically ill rheumatologic patients. And the way to be able to take care of those patients was to dual train.”
Gretchen Henkel is a health and medical journalist based in California.