Inam Haq and Ian Giles explain why you should seriously consider this expanding specialty

Rheumatology covers a range of conditions from self limiting but troublesome musculoskeletal problems to progressive multisystem disorders. In developed countries, musculoskeletal and arthritic problems are the commonest cause of longstanding disability in adults. This is particularly true of back pain in under 50 year olds and osteoarthritis in older adults. Osteoporosis is a sizeable public health problem, with one in three women likely to have an osteoporotic fracture of the wrist, hip, or spine in their lifetime. As the population ages, musculoskeletal problems increase, and it is essential that there are rheumatologists to deal with these problems.

Rheumatology affords an excellent opportunity to practise clinical medicine in its broadest sense. Rheumatologists are often called the last of the general physicians. Autoimmune diseases such as vasculitis and systemic lupus erythematosus affect many systems, so good general medical knowledge is essential. These conditions have profound psychosocial components, and rheumatologists need a broad, empathetic approach to management. This wide spectrum of disease makes the specialty both challenging and exciting.

Rheumatology can be practised as a single specialty or in combination with general internal medicine. Practice has changed considerably over the past 15 years and is now predominantly a busy outpatient specialty, in which patients of all ages with a wide variety of acute and chronic musculoskeletal problems are seen (box 1). Paediatric rheumatology is a separate specialty, but specialists in adult rheumatology with an interest can do combined clinics. Rehabilitation medicine is also separate but has close links to rheumatology.

• Back pain and soft tissue problems
• Inflammatory arthritis

• Autoimmune rheumatic diseases:

• Paediatric and adolescent rheumatology
• Osteoporosis and other metabolic bone diseases
• Sports medicine

The number of clinics per week varies according to the post. Academic consultants tend to do fewer clinics than full time NHS consultants, who average four clinics per week. Clinics can be demanding, especially in single handed posts with little multidisciplinary support. These posts are becoming less common as the specialty expands with appointments of new consultants and increasing recognition of the role of allied health professionals like nurse specialists.

NRM, YORK/HIP

Some departments hold outreach clinics at general practitioners' surgeries, and requirements for this may increase in the future. Home visits may be undertaken depending on local need. On-call commitments for rheumatology are generally less onerous unless you happen to be responsible for a large cohort of patients with autoimmune rheumatic disorders.

Inpatient workload varies depending on where you work and whether you have a subspecialty interest--for example, connective tissue disease. Rheumatologists are often asked to help in diagnosis, and also liaise with emergency doctors regarding rheumatological emergencies such as acute hot joints or flare of existing illnesses such as rheumatoid arthritis. Rheumatology is also a very practical specialty. In addition to performing many procedures, rheumatologists are increasingly training in diagnostic ultrasound rather than relying on their radiologist colleagues.

Rheumatologists liaise with primary care doctors, orthopaedic surgeons, and multidisciplinary teams comprising nurses, physiotherapists, occupational therapists, and podiatrists, without whom they could not do their job.

Rheumatologists are fascinated by the mechanics of the human body, enjoy clinics, and the doctor-patient relationship. Good communication and diagnostic skills are required in order to tease out specific musculoskeletal disorders from what are often non-specific complaints.

Caring for patients with chronic progressive conditions that have no cure and where the best available symptomatic treatments prove ineffective or toxic is challenging. These patients need support, understanding, and for you to acknowledge the effect of the condition on their lives. Patients may become frustrated when treatments do not work or when side effects develop, and negative self images due to medication, such as steroids, or direct disease effects should not be underestimated.

It is often frustrating to see treatments fail and patients continue to suffer. Adolescent and young adult patients with severe arthritis or connective tissue disease often worry about whether they will be able to work or have a family. Rheumatologists have to discuss personal subjects with patients in a sensitive manner. Empathy and patience are vital. Patients in a rheumatology clinic often need more time than the standard 10 or 15 minutes on the clinic timetable. This is one of the reasons why clinics can run late, but both patients and doctors benefit from taking more time.

It is also vital to enjoy and have an aptitude for practical procedures (such as joint aspiration and injection, synovial fluid microscopy, epidural injections and nerve root blocks, nerve conduction studies or electromyography, and soft tissue and joint ultrasound) as well as the ability to function as part of a multidisciplinary team.

Knowledge of immunology is important as this forms the basis to understanding the pathology behind rheumatic diseases and the rationale behind the new biological treatments (which are increasingly used to treat inflammatory joint diseases) Diagnosing and treating a variety of musculoskeletal disorders requires a good understanding of anatomy.

Clinical training includes orthopaedics and rheumatology. This gives you a taste for the specialty, but you may not get as much experience as you would like. If the subject interests you it may be worth thinking about doing an intercalated degree in a rheumatology related discipline such as immunology.

The arthritis research campaign awards an annual prize to each UK medical school and a new elective bursary prize will also be available to each medical school soon. The prizes may be for an essay, case report, or multiple choice question test. If you are interested contact your medical school department of rheumatology for further details.

Hands-on experience in rheumatology will help you decide if this is the career for you. It is vital if you are successfully to obtain a national training number (NTN) in rheumatology as competition for posts is fierce.

Firstly, find an SHO rotation that includes rheumatology. If this is not possible, some rheumatology posts are "standalone" and can be applied for after your general medical rotation has finished. The part 1 membership for the Royal College of Physicians (MRCP) is often required for these posts.

Secondly, introduce yourself to the rheumatology team in your hospital. Arrange to sit in on clinics if possible. This is a good way of making contacts and gaining experience. The RCP has regional specialty advisers for each medical specialty. They will also be able to put you in contact with people who may be able to help.

Thirdly, getting involved in research may be helpful. This allows you to gain practical experience and to publish papers in rheumatology journals, which will help in your application for an specialist registrar (SpR) post.

Fourthly, locum SpR appointments are a good way to gain experience at a more senior level and make local contacts. This experience will count towards your clinical training once you become an SpR if you are in a locum appointment for training (LAT) post. Locum appointment for service (LAS) posts do not count for SpR training, but this should not stop you from applying.

Fifthly, application forms for SpR posts all have a section for management and teacher training courses attended, so it is essential to attend some.

• Excellent opportunity to practise clinical medicine in its broadest sense
• Practical application of anatomy and immunology to help make a diagnosis and guide treatment
• Holistic approach towards patient care, taking into account not only their medical problems, but also the effect of these problems on their social and psychological wellbeing
• A long-term relationship is built up between doctor and patients with chronic rheumatic disease
• Opportunity to work as part of a multidisciplinary team
• Lots of opportunity to develop a subspecialty interest and combine this with research and general internal medicine
• Good opportunities for flexible training
• Manageable on-call duties

• Treating chronic incurable diseases is demanding and sometimes frustrating
• Workload is mainly elective
• The mainly out patient nature of the specialty may not appeal to all
• Some rheumatology departments that are not integrated with general medicine may feel cut off from the rest of the hospital
• Rheumatology may be regarded as a low profile specialty when compared to cardiology or oncology, for example
• Lack of a national service framework (England only) for arthritis makes it difficult to achieve a high political profile

There are currently approximately 210 SpRs, and 480 consultants in the United Kingdom; the number of training posts in rheumatology and general internal medicine varies between regions. There are excellent opportunities for flexible training.

Competition for NTNs in rheumatology is high at the moment, and previous clinical or research experience of the specialty is helpful. Accreditation in rheumatology alone requires at least four years of training, of which at least 36 months should be in rheumatology alone. Dual accreditation in rheumatology and general internal medicine requires at least one further year of training in general internal medicine.

On-call is not a part of all posts, but the rheumatology posts that include it are usually non resident while the on-call posts in general internal medicine are resident (constituting acute medical take).

Proposed changes to the SHO training programme will change the format of training. Accreditation will first be obtained in general internal medicine, and then in a subspecialty interest. Any new NTNs are most likely to be outside London.

HUGH TURVE/SPL

Some SpRs take time out of their clinical training to do a period of research of one to three years, often aiming towards an MD or PhD. Research can be in basic science or immunology, but also in medical education, epidemiology, or clinical studies. Several regions provide a part time rheumatology MSc, which may be more appealing than an MD or PhD.

Research is not compulsory but allows you to step back from the rigours of clinical medicine and develop a specialist interest that will benefit your professional development and subsequent clinical practice.

Rheumatology is an exciting and expanding field and, like any specialty, has its advantages and disadvantages (see box 2). Rheumatologists require excellent communication skills and general medical knowledge, and they have to work closely with other health professionals. Numbers of consultants will certainly increase, and the opportunities for research in both laboratory and clinical fields are good.