How to Attract Trainees, a Pan-Canadian Perspective: Phase 1 of the “Training the Rheumatologists of Tomorrow” Project

Participants

There were 103 participants, 52 learners and 51 professionals, 76% of whom (78/103, 46 learners and 32 professionals) were surveyed. The other 25 participants (6 learners, 19 professionals) were interviewed. Many participants were women. The mean age of respondents was lower for learners than professionals. Two-thirds of surveyed learners planned to work in an academic hospital where 70% of the professionals currently worked. Interviewed professionals had, on average, worked in rheumatology for 13.4 years (range 3–30 yrs; Table 1). These numbers are typical of the larger populations from which the samples were drawn.

The response rate was calculated separately by site and was the proportion of invited participants who joined our study. Overall, 12% of the invited learners (range 3–33%) and 34% of invited professionals (range 26–83%) participated in our study. The lower response rates were from larger programs that had sent out considerably more invitations.

Reasons for initial interest in rheumatology

The leading reasons for interest in this field were related to work life characteristics, followed by rheumatological diseases, and then patients. Junior learners more often mentioned an interest in rheumatological diseases; senior learners and professionals noted specific elements of work life (Table 2A). Learners were more interested in the type of practice, and professionals highlighted intellectual challenges (Table 3A). As one professional noted, “[Rheumatology] challenges you to be a good internist” (F/A-1). Some students also found this to be important, describing it as “being like a modern-day detective” (Sr-1 IW). Learners were also impressed with a positive work environment from “working with like-minded individuals” (Jr-20) in “an excellent culture of collegiality” (Jr-17). They noted that rheumatologists were pleasant and content, or as one fellow wrote, “most rheumatologists, according to objective studies that have looked at quality-of-life measures, are on the high end of the satisfaction and happiness scale for all specialties in medicine. It’s important this gets projected to trainees” (Sr-4 IW).

Comments about rheumatological diseases said that they are interesting, diverse, or multisystemic. Learners described them in general terms as “les plus belles maladies de médicine interne” [“the best diseases in internal medicine”] (Sr-7), whereas professionals focused on their being diverse and complex. Learners more often mentioned being interested in patients, although both groups described them as a diverse and complex population. Role models and future earnings were among the least frequently mentioned reasons for an initial interest in rheumatology.

How to attract learners to rheumatology

The 3 leading themes were to increase exposure, specific education methods, and creating opportunities for more hands-on experiences. Together, they accounted for nearly 70% of all suggested ways to attract learners. Junior learners focused on specific teaching methods, senior learners on the need for hands-on experiences, and professionals on increasing exposure in general (Table 2B).

Comments about increasing exposure generally emphasized creating interest and awareness for learners at various stages of their training (Table 3B). In the words of one professional, “no one is going to pick rheumatology who has never done rheumatology, so anything a program can do to get [learners] to … spend time in rheumatology is going to be the biggest payoff” (F/A-7 IW). A resident agreed when he stated, “Early exposure is good for making rheumatology something that people will consider … [The] best place to target this would be during internal medicine rotations, but also the MSK [musculoskeletal] unit with first- or second-year medical students [because this] is where you get your first exposure to rheumatology” (Jr-1 IW).

Professionals had very specific recommendations on how to promote interest in the field, such as “increasing exposure to young, recently recruited rheumatologists” (F-2) and “[informing them] about what it is like to be a rheumatologist” (F/A-6). Some suggested focusing attention on medical students by such means as “collaborating with the undergraduate program to reach out to students to give them opportunities to work with us” (F-8) and “putting an emphasis on getting clerks exposed to the service and our clinics” (F-10).

Junior learners and faculty in particular suggested offering more lectures and clinical skills sessions with interesting cases. Teaching was crucial, with some participants noting that “people get turned away from rheumatology because it is often not well taught” (Jr-9). Faculty/administrators also recommended changes in educational approaches for learners, such as ensuring that “[sessions with] patient partners include not just joint exams, but also exposure to patients with [systemic lupus erythematosus], myositis, vasculitis, etc. to give medical students a better feel for what all rheumatology encompasses” (F/A-13).

The third theme, more hands-on experiences, included suggestions such as providing more opportunities for preclinical observerships, more spaces for rotations in clerkship, and making rheumatology “a mandatory rotation in the internal medicine residency curriculum” (F-4). Few participants specifically mentioned mentors, but clearly referred to activities that clinicians and educators do as role models. As one professional explained, “You meet special people along the way who leave an indelible impression on you. Exposure is so important to really turn somebody on to rheumatology. Remember: there may be a future rheumatologist in the audience when you’re teaching” (Fac-1 IW).

Messages for undergraduates about rheumatology

The 3 leading themes for this topic were, in rank order, to emphasize positive aspects of working as a rheumatologist, future career opportunities, and the lifestyle of rheumatologists. These accounted for 61% of all recommended messages. Junior learners and faculty/administrators mostly suggested highlighting career opportunities, whereas senior learners and faculty-at-large focused on telling students about work life issues (Table 2C).

Junior learners, more than the other respondent groups, suggested informing students about how rapidly the field is expanding. In contrast, senior learners and professionals wanted to tell audiences that “if you love to be challenged, this is your subspecialty” (F/A-13). Senior learners and professionals tended to recommend that messages describe the type of practice that rheumatology is, such as it being an “outpatient-based specialty that is very clinical” (Sr-8) and “a very hands-on discipline” (F-9) with “a nice mix of procedural and cerebral work” (Sr-13). There were also many opportunities to open “a diversified practice with many areas of interest to explore” (F-6), such as “specializing further to create niche areas of interest, including research” (F/A-13). Some senior learners also suggested describing the collegial work environment in this field because “les rheumatologues eux mêmes sont des gens gentils, généreux, sympathiques, et aiment la vie et leur travail” [“rheumatologists are nice people — generous, friendly, and love their life and work”] (Sr-10).

Job-related messages included information on both the availability and flexibility of work, with professionals focusing on availability of jobs and learners on career flexibility. As one professional noted, “[We should tell them] there’s a good career opportunity in rheumatology” (F/A-8 IW). Typical messages from learners were to “[tell them that rheumatologists] can work anywhere” (Jr-7).

Messages about the lifestyle of rheumatologists focused on both quality of life and having a good work-life balance (Table 3C). For learners, there were no clear patterns to their suggestions, but professionals emphasized a positive quality of life, noting “[there is] less stress than [in] many other specialties … [because] it is extremely rare to have to attend a call at night” (F-13). They also suggested telling students the following: “according to a recent survey, we are the happiest specialists. What more do you need to say?” (F-05).

Negative messages about rheumatology

There were only 32 comments about problems with being a rheumatologist, usually provided as messages to share with medical students wanting to learn about this field. Most of them related to rheumatology as a clinic-based nonprocedural chronic care discipline. Participants recommended providing information such as “doit aimer l’examen physique” [“you have to love doing physical exams”] (Sr-12), “a consult can take hours” (Sr-1), and “if you don’t have patience, don’t do rheum!” (F/A-7).

Very few respondents commented about low remuneration, noting that rheumatologists are “at the bottom of the pay scale for internists because we have no procedures” (F/A-8), but that “[it is] not a fantastic salary, but reasonable” (F/A-10). Some participants also noted that students should know it can be stressful to work with a large number of patients with chronic pain. As one explained, “Sometimes the severity of the diseases can be emotionally challenging” (Sr-5).