The Secret Lives of the Rheumatologist

Clark Kent, Hannah Montana, Dexter Morgan, David Bowie and your friendly neighborhood rheumatologist: What do all of these people have in common? Chances are, they live secret lives we rarely get to peer into. Unlike Superman, Miley Stewart, Dexter Morgan and Ziggy Stardust, rheumatologists are very much real, flesh-and-blood characters. Rheumatologists also have secret lives that are much more fascinating and intriguing than those of these rock stars, superheroes and sociopathic detectives. What do I mean? Let’s rheuminate!

1. The Adventures of the Practicing Rheumatologist

To be fair, there is no prototypical rheumatologist. Our job descriptions are wide-spanning, with many of us leading in communities through private practice, some devoting our careers to research and education in the academic sphere, and others still in industry, public service and beyond. Despite this heterogeneity, I would contend that most rheumatologists are still living more than one life. In fact, the job description demands it.

For example, the everyday work of the rheumatologist requires more than 24 hours to complete. We have extended ourselves from being doctors for musculoskeletal conditions, from which the original rheum prefix in rheumatologist derives, to becoming immunologists in our own right. Therefore, for every patient we see in clinic, there are two clinician minds stuffed in one body.

Add to that the critical roles that we play as preventive health specialists. Our patients, living with chronic immunologic conditions, often require detailed, holistic guidance that goes well beyond inflammation. From ensuring timely vaccinations to offering lifestyle modifications for preserving cardiovascular and bone health, our conversations frequently mirror those of primary care providers. In many ways, we serve as the integrators of long-term health. So add another secret clinician to the mix.

Further, we are inherently (and secretly) advocates. Whether it’s battling for prior authorizations, writing peer-to-peer appeals or helping patients navigate disability services, rheumatologists spend considerable parts of our day fighting large systems that have not been built to accommodate patients with chronic autoimmune disease. Sometimes, this advocacy role can occupy more of our time than diagnosis or management.

Finally and perhaps most secretly, we are writers. With each note, we attempt to document the complexity of our patients’ journeys in ways that are meaningful to ourselves, our colleagues, our patients and future historians of care. We have to do this as rheumatologists because our patients are that complicated. And yet this unique style of writing and documenting is rarely, if ever, discussed. It is as if it is another secret identity.

Perhaps that is why rheumatologists are often overthinkers. Our work demands a high tolerance for ambiguity, a relentless compulsion to synthesize and resynthesize differential diagnoses, and the ability to mentally model immune pathways and musculoskeletal biomechanics in real time. If you had to explicitly write a job description for all that we do, you would probably say that the only capable candidate would be Clark Kent (aka Superman).

2. Secret Identities at Home

Even then, these secret identities at our workplaces do not encapsulate the most important parts of our lives. The Rheum After 5 series in The Rheumatologist offers a window into the unexpected dimensions of our colleagues. We meet rheumatologists who are photographers, fiction writers, marathon runners, classical musicians and community volunteers. Their stories are inspiring, and still these profiles are only the tip of the iceberg in terms of the lives and identities of rheumatologists.

At this point, we can’t avoid this conversation so let’s just get through it. The words work-life balance get tossed around a lot, but, in my opinion, the phrase is often more a marketing slogan than an actually attainable goal. The reality of the balance is far more complicated, and it almost seems mythical sometimes. The many identities we take at work often spill into the identities we assume at home.¹

Maintaining dual—or triple or quadruple—identities is no small task.

Let me give an example. One day, my then 4-yearold, oldest daughter was playing doctor with her toys. Surprisingly, she didn’t pick up a stethoscope or a reflex hammer. Rather, she took a folded piece of paper and pretended like she was typing. To her eyes, that is what a doctor does—write notes and manage inboxes. I had worked hard to keep that aspect of my life, the endless clinic notewriter, a secret from my kids, but kids seem to know everything.

It was a clarifying moment to me about the elusive work-life balance. Achieving work-life balance requires secret identities that we can toggle on and off. In other words, to be present in one role, we must necessarily be absent in another. Unlike those secret identities at work, there is little room for overlap at home where our domestic identities take precedence.

Still, these identities seem to blend into one another. I cannot be the rheumatologist (or the allergist for that matter) that I am without referencing the person I am at home. I know how much it means to be able to hold kids in my arms without pain, and I feed those insights into empathic dispositions in clinic. As watchers of Hannah Montana know, even Miley Stewart is touched by her pop star alter ego.

3. Choosing Our Secret Lives

Of course, maintaining dual—or triple or quadruple—identities is no small task. The prospect of burnout stalks every identity and is often disguised as noble sacrifice. So how can we stay sane while managing the paradoxes of being a modern rheumatologist?

One strategy is to call out the myth of efficiency. The belief that we can do more with less indefinitely has seduced much of our profession. We install productivity-enhancing apps, sign up for documentation accelerators, and now, increasingly, turn to artificial intelligence to manage our messages and even draft our notes. These tools may appear superficially to be useful, but they risk reinforcing the most dangerous idea that with enough efficiency, we can assume infinite identities in a finite world.²

In fact, the only identity that rheumatologists do not embrace, whether at work or at home, is that of a robot. Rheumatologists, on the whole, are repulsed by the notion of being a cog in the machine. We are built to reflect on mortality, to wrestle with dangerous truths and to relieve the pain of others. The more we chase perfect productivity, the more we risk embracing a secret life that is deadly to everything that animates us.

More to the point, a culture of intentionality is needed to manage the secret identities we call our own and the ones we would seek to avoid. The poet Mary Oliver wrote that “attention is the beginning of devotion.” In rheumatology, the act of attending to our secret identities, tending to them and providing them the resources to grow in concert with one another, is the first step toward devoting ourselves to well-being.³

Intentionality also means building a culture of collegiality. It is only when we recognize that our secret identities are not secret but shared that we initiate sharing these identities and the burdens that come alongside them. When we share our lives with one another, including our frustrations, our joys, our pet peeves about EHRs, we let others into our secrets and foster a sense of professional collegiality. There becomes no room for a sociopathic Dexter Morgan.

4. Coalescing Our Secret Selves

Needless to say, keeping secret identities is exhausting. There are things, though, that we can do as individuals to help relieve that burden. First, we have to embrace a shift in mindset.

One approach I recommend is creating done lists rather than just to-do lists. These reflective inventories help illuminate accomplishments that otherwise disappear into the background noise of our busyness. They expose the accomplishments of our hidden selves to others. They openly celebrate the many roles we perform each day rather than hide them away. By honoring what we’ve done, whether it’s making a tough diagnosis, offering reassurance to a struggling patient, or cooking dinner with our family, we reconcile our secret identities into a wholesome singularity.

Setting boundaries is another key. For example, I turn off email notifications after 5 p.m., unless I am on call. I have a poster saying “Just say no to new projects” to remind me to only pursue opportunities that align with my values and personal goals.⁴ Most importantly, I’ve had to train my mind to forget the emotional burdens from the workplace and set hard boundaries when I reach my front door. In short, these boundaries protect the integrity of both our professional and personal secret selves—they enable us to live fully in each identity without sacrificing the others.

Finally, I promote a culture of intentionality within my own work. Through mindfulness, I constantly reinforce to myself that I am the sum of my present moments. Who I am at that one moment in time is who I unequivocally am, without any other compromising or conflicting identities. After all, I only have a finite amount of time, both in my day and in my career. Living fully in the present, with an eye toward preserving my future self, is how I can ensure that my many secret lives remain as vibrant as David Bowie’s were.

Conclusion

So what do rheumatologists and fictional characters like Clark Kent, Hannah Montana, Dexter Morgan and Ziggy Stardust have in common? Quite a lot, it turns out. We all live multifaceted lives, toggling between roles with agility and purpose. We occasionally protect these alter egos much to our own detriment and promote versions of ourselves that may not be entirely true to our spirit. Regardless of whichever identity we assume, we hide from ourselves a fundamental truth: Literally everybody knows about our secret lives.

The key is to live comfortably with these conflicting, hidden identities. By embracing the richness of our roles in upholding health, by nurturing our personal passions outside work, by building intentionality into our mundane routines and by reclaiming the short moments of joy that shape our long days, we coalesce our secret identities into a manifest whole. Each of us becomes the storyteller, the mentor, the artist, the advocate and the healer, all in one. In short, we become the rheumatologist.

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.

References

1. Gragnano A, Simbula S, Miglioretti M. Work-life balance: Weighing the importance of work-family and work-health balance. Int J Environ Res Public Health. 2020 Feb 1;17(3):907.
2. Burkeman O. Four Thousand Weeks: Time Management for Mortals. New York: Farrar, Straus and Giroux. 2021.
3. Foer F. Attention is the beginning of devotion. The Atlantic. 2019 May 9. https://tinyurl.com/fh5m2vdb.
4. Schrager S, Sadowski E. Getting more done: Strategies to increase scholarly productivity. J Grad Med Educ. 2016 Feb;8(1):10–13.