Specialty career profile: rheumatology and acute medicine

Dr Alan Hakim, Consultant in rheumatology and acute medicine and director of strategy and business improvement at Whipps Cross University Hospital NHS Trust, shares his experience of what influenced him in choosing rheumatology and acute medicine, what training involves and what it's like to work in the specialties.

What influenced you to choose your specialty?

I knew I wanted to specialise in an area of medicine that dealt with complex multi-organ pathology. I had had experience of haem-oncology and infectious diseases as a house officer and junior SHO, where patients similarly present with complex diseases.

I didn’t make the link with autoimmune rheumatic disorders until I started nephrology in my second year as an SHO; here I was exposed to vasculitis and its association with rheumatoid arthritis, lupus, and pulmonary-renal syndromes. Patients were presenting with severe inflammatory arthritis, renal disease, lung disease, neuropathies, carditis, and skin disorders. At the time experimental biologics were just being tried, successfully, on our patients – I was hooked!

Biologics are now an aspect of everyday therapy for our patients, making my job more satisfying than ever. Little did I know at the time that I would later be exposed to so much more in the specialty of rheumatology that I have found equally rewarding in my clinical practice and research – hereditary disorders of connective tissue, metabolic disorders, bone disorders, mechanical degenerative disorders, aspects of sports medicine, soft tissue disorders, chronic pain and its associations with autonomic dysfunction.

I always wanted to maintain my general medical skills and not to sub-specialise to too great a degree. Whichever specialty I may have chosen I would have wanted to do acute medicine as well and work in a specialty that gave me the opportunity to practice general medicine. Rheumatology is a specialty that needs you to be able to do just that; and in every aspect of health; physical, psychological and social.

What training do you have to do to get into rheumatology and acute medicine?

General medicine and MRCP exams.

What rotations did you do in your training? What did you find helpful?

As a house officer I worked in haem-oncology, infectious diseases, and endocrinology/general medicine. As an SHO I gained further clinical training in cardiology, nephrology and transplant medicine (renal/hepatology), and neurology/neuro-surgery.

I think a broad grounding in any areas of general medicine is essential for the foundation year 2 and core medical trainee 1-2 or specialty training 1-2 years; but for me working in haem-onconcolgy, infectious diseases and nephrology was the opportunity to manage patients with multiple complex disease-related pathologies.

I then joined a 3 year registrar rotation that converted to a 5 year SpR (now your ST3 + specialty rotation). Three of my years were in general rheumatology and acute medicine at district general university teaching affiliated hospitals; one year was in tertiary metabolic bone disorders, and one year in tertiary autoimmune rheumatic disorders. For me the most helpful thing about the whole rotation was the widest possible exposure to the breadth and complexity of rheumatology.

Do you work closely with other specialties?

Yes; osteoporosis, orthopaedics, dermatology, chest medicine, nephrology, neurology, and pain management in particular.

In what ways is your job satisfying?

• the long-term relationship one builds with patients and their families
• seeing our patients respond to the latest disease modifying drugs and biologics and get their ‘life’ back
• helping patients with complex mechanical disorders find relief in physical therapies, adjustments to lifestyle, and coping strategies
• training junior doctors in the art of general medicine
• working with a wide range of health practitioners – nursing, therapist, clinical psychologists
• working in such a vibrant arena of clinical research.

What are the possibilities for your future career progression?

I enjoy having a clinical, teaching, clinical research, and management portfolio. I might have chosen to pursue teaching or research to a greater degree practically and academically but I moved to clinical management and I am now an executive director of my trust. A career in rheumatology offers all these things depending on your interests, which often develop over time and may not be obvious to you early in your career.

What are your typical working hours?

My ‘day job’ whether doing rheumatology or management is Monday to Friday and typically 8am–6pm. I also do medical on-call.

Given the expansion in acute physicians over the last few years the rotas have become much more sociable and family-friendly – mine is a 1 in 20 week day and a 1 in 10 split weekends. Out of hours, our acute rheumatology admissions (which are very few as the vast majority of our patients are seen in clinic), are managed by the medical on-call team.
A number of hospitals (particularly the tertiary hospitals) also run out-of-hours on-call for rheumatology. The rotas will vary according to number of rheumatologists in the trust but typically might be a 1 in 8 or less.

Any doctor working in education or research will tell you that teaching/application preparation including writing or publishing, often involves ‘burning the midnight oil’ – but we love the results and that’s why we do it.

Working as an executive director means it is inevitable that there will be early morning and evening meetings on the odd occasion and administrative work that needs completion outside the normal working day.

There are also opportunities for travel to international conferences for both continuing professional development and to present research. In rheumatology this typically includes annual European, USA, and East Asian conferences, as well as many meetings held throughout the year within the UK.

Are there opportunities for teaching and research?

The specialty is awash with excellent clinicians, academics, educationalists, and managers in rheumatology and general medicine – that is what makes it so vibrant to practice in, and such a rich training ground. Research grants are highly competitive.

All my final year SpRs (every year of my 12 years as a consultant) have gone on to get excellent consultant posts in the type of environment they most wanted; proof that getting the best training, preparation, and support in the broadest sense across their SpR years is crucial.

Do you work closely with other healthcare colleagues or groups?

Rheumatology is a multidisciplinary specialty. We work with nurse practitioners, general practitioners, all areas of ‘physical’ therapies, occupational therapy, podiatry, clinical psychology.

I have also work with:
• the Royal College of Physicians
• the British Society for Rheumatology
• Arthritis UK
• the Royal Society of Medicine
• The Kings Fund
• the NIHR
• Arthritis Musculoskeletal Alliance
• medical charities
• programme boards working on local and regional service re-design initiatives
• pharmaceutical companies
• journals – as a reviewer, as well as publishing my own research
• publishing houses – as a reviewer, as well as publishing my own books.