As a medical student, do you ever wonder what it’s like to specialize in rheumatology? Meet Amish J. Dave, MD, MPH, a rheumatologist and a featured physician in the AMA’s “Shadow Me” Specialty Series, which offers advice directly from physicians about life in their specialties. Check out his insights to help determine whether a career in rheumatology might be a good fit for you.
The AMA Specialty Guide simplifies medical students’ specialty selection process, highlights major specialties, details training information, and provides access to related association information. It is produced by FREIDA™, the AMA Residency & Fellowship Database®.
Learn more with the AMA about the medical specialty of rheumatology.
“Shadowing” Dr. Amish Dave
Specialty: Rheumatology.
Practice setting: Medical center.
Employment type: Employed by Virginia Mason Franciscan Health in Seattle and on Bainbridge Island, Washington. Virginia Mason Franciscan Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Years in practice: 11.
A typical day and week in my practice: Typically, I have clinic four days per week, from 8 a.m. to 5 p.m. I practice at two clinic sites, splitting time equally between Virginia Mason Medical Center, in First Hill, and Virginia Mason Franciscan Health Medical Pavilion, on Bainbridge Island. When I’m at the medical center, I often consult in the hospital setting, where patients tend to present with more severe conditions, such as lupus or vasculitis, or are experiencing complications from common rheumatologic conditions.
I work with six adult rheumatologists, one nurse practitioner and one colleague from our research center, Benaroya Research Institute. We also receive inquiries and consults for pediatric and adult rheumatology patients from across the Pacific Northwest. But we haven’t yet consulted pediatric patients because we don’t have pediatric rheumatologists in our practice.
Additionally, I serve as the director of continuing medical education for Virginia Mason Medical Center and contribute to health equity and diversity initiatives through an employee-resource group within the Virginia Mason Franciscan Health hospital system.
The most challenging and rewarding aspects of rheumatology: Washington has one of the lowest numbers of rheumatologists per capita in the U.S. Consequently, our patients often present with complex autoimmune diseases and a higher incidence of complications compared with patients in other regions.
This complexity is compounded for some patients who may have to travel very long distances to see rheumatologists, who are usually concentrated in metropolitan areas such as the Puget Sound. We have to think about access to care and many social determinants of health when considering the optimal treatment plans for our patients. For example, the needs and challenges of a patient in the Queen Anne neighborhood of Seattle will greatly differ from those of a patient who lives on Kodiak Island in Alaska.
Also, while telemedicine has helped bridge some of the divide, we face significant hurdles in obtaining licensure and maintaining credentials in outside states. To care for my patients, I have to maintain licenses in California, Idaho and Alaska in addition to Washington, and the administrative and financial burden of doing so can be challenging.
On the most rewarding aspects, I love helping people control their inflammatory disease processes. There have been miraculous advancements in the last 20 years for patients with autoimmune diseases. A plethora of medications have emerged to manage conditions like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis, Crohn's disease, ulcerative colitis, interstitial lung disease, lupus and vasculitis, among others.
It's amazing to be able to stop the progression of joint breakdown, prevent scarring of the lungs, help mobility and prevent organ failure that might have afflicted earlier generations. Working with patients to find the best treatment options for them, guiding them through infections that might arise from suppressing their immune systems, managing or mitigating side effects and getting patients to the right specialists to care for them is part of what we do every day. This work can bring a great deal of joy!
The impact burnout has on rheumatology: Burnout is a major problem in rheumatology and has been compounded by strains on the health care system and burdensome practices by insurance companies. The insurance industry has created time-consuming prior authorization requirements, along with pharmacy benefit management practices that not only disrupt hospital and independent pharmacies but also prevent rheumatologists’ access to prompt peer-to-peer reviews of complex and nuanced medications that might be critical for our patients.
Fortunately, there is a growing awareness within the health care landscape regarding these practices and their role in increasing physician burnout and moral injury. Rheumatologists, along with their patients, stand to benefit from initiatives aimed at reducing medication costs, streamlining prior authorization processes and prioritizing patient-centered care over profit-driven motives in medicine.
How Virginia Mason Franciscan Health is reducing physician burnout: Virginia Mason Franciscan Health has several wellness initiatives, such as an annual holiday dinner and a newly reopened physician's lounge to foster collegiality. We also have a fund dedicated to facilitating gatherings among physicians, which has shown a marked reduction in physicians’ reports of job dissatisfaction.
About eight years ago, I worked with the Virginia Mason Franciscan Health Wellness Fund to create an art-and-medicine program for our internal medicine residents and teaching faculty. This initiative aimed to help physicians learn how to look at art to become better visual diagnosticians and promote overall well-being. I am hoping to expand on this work in the near future with a larger audience of doctors.
However, more can be done generally to support physicians' wellness by implementing formal wellness programs and appointing wellness leaders and hospital ombudspersons to round out existing initiatives.
How my lifestyle matches, or differs from, what I had envisioned: I enjoy the diversity that my specialty allows, including working in different locations, teaching internal medicine and family medicine residents, and helping my patients enroll in clinical trials at Benaroya Research Institute. I am a person who enjoys doing different things every day, and I always find my work challenging and varied.
On the other hand, early on in my career, I had anticipated spending more time with patients and less time engaging with administrative tasks and insurance-related matters. Balancing clinical responsibilities, research pursuits, educational commitments and personal projects while nurturing relationships with friends and family remains an ongoing endeavor.
In addition, I often need to remember to take time for myself. I have been prioritizing personal time through solo travel. Recent adventures have taken me to Ladakh in the Himalayas, Ecuador, St. Lucia and Indonesia.
Skills every physician in training should have for rheumatology but won’t be tested for on the board exam: Rheumatology is not an algorithm, and rheumatologists navigate through shades of uncertainty. Unlike specialties where management protocols are checklist-driven, rheumatology hinges significantly on clinical judgment informed by a patient’s history and physical examination. Therefore, it is difficult for any board exam to simulate skills like assessing the inflamed joints of a patient with rheumatoid arthritis.
A good rheumatologist has to be patient and diligent in weeding through the many details in a patient's history, report and presentation to find the key pearls that may suggest disease symptoms, complications or changes in status.
One question physicians in training should ask themselves before pursuing rheumatology: Are you comfortable not knowing what a patient has?
Rheumatologists and their patients often spend considerable time, spanning many months to years, diagnosing and determining the optimal treatment for patients. No two patients with rheumatoid arthritis will respond in the same way to the same medication. A good rheumatologist is comfortable embracing ambiguity and guiding patients through sometimes very arduous processes.
Rheumatology requires a customized approach for each patient. That means working together with the patient to understand their experience and symptoms, identifying supportive treatments and solutions—often beyond the formulary—and sharing insights on the outcomes of each case to increase shared knowledge.
Additional advice I would give to students who are considering rheumatology: Despite the appeal of other fields, it is noteworthy that rheumatologists often report higher job satisfaction and adequate compensation for their work. Since becoming a rheumatologist, I have often found myself joyful, surprised and challenged.
Also, I cannot recall when I was last bored at work. There is always so much to do in rheumatology, and there are so many great stories in the clinical and hospital settings. Make sure you write down some of your good stories—you may find them to be positive reference points at times throughout your career.
