The Transition from a Rheumatology Fellowship to Private Practice

The transition from being a rheumatology fellow to being in private practice is significant. As I reflect on the past two years, I want to share my observations and begin a conversation about how to prepare rheumatology fellows for careers as practicing rheumatologists. The difference between learning about rheumatology and practicing rheumatology is nuanced. Upon joining an independent private practice, I quickly discovered how much I had to learn about the practical aspects of caring for rheumatology patients. My fellowship taught me the science of rheumatology. I had the opportunity to treat many different diseases and saw a wide variety of both simple and complex cases, from gout to central nervous system vasculitis. By the end of my fellowship, I was comfortable practicing independently. I was quoting my favorite studies by journal, volume and issue with my co-fellows and attendings. I was well-versed in the literature and prepared for the board exam.

A seismic change occurred when I started my first job. Although I was very familiar with how to properly treat rheumatologic conditions, I found new challenges in patient management. Working through insurance companies and the complexities of pharmacy benefit managers were not entirely new, but suddenly became more complex. I had done many sample board questions, but none of those questions had ever addressed which insurance companies required a prior authorization for which medications. Nor did they address how your practice may be affected by the reimbursement for infusions vs. injections, buy-and-bill medications and visits, for example.

I also had to learn how to build my practice. In a university system, many of the referring physicians are in house and many have an office or clinic next to yours. Medicine is often easier to practice when you know the person receiving your notes. In a private practice, you need to learn to reach out to referring physicians after seeing patients. Much more time was spent introducing myself and discussing how I could help care for their patient populations.

A rheumatology fellow has, appropriately, less input into the day-to-day operations of a practice. The focus of a fellowship should be on learning medicine. This changes in private practice when you can suddenly shape the direction of your practice. What insurance should I accept? What are the documentation requirements for appropriate evaluation and management coding? What is needed in the chart from a medical legal standpoint in case I get sued? How can I use the ancillary services available within the clinic to enhance patient care?