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20 Questions: Natalie E. Azar, MD – Rheumatology

Dr. Natalie E. Azar is assistant clinical professor of medicine and rheumatology at the Center for Musculoskeletal Care NYU Langone Medical Center, as well as medical contributor to, member of the admissions committee for NYU School of Medicine, and instructor of the Physical Diagnosis Course at NYUSoM. She received a bachelor’s degree in psychobiology from Wellesley College (1992), where she was a Phi Beta Kappa (1991), Durant Scholar (1992), and Who’s Who Among American College Students (1991). Azar received her Doctor of Medicine from Cornell University Medical College (1996), with honors for academic excellence in anesthesiology (1998). Dr. Azar completed both an internship and residency in internal medicine at New York University Langone Medical Center (1996-97, 1997-99), and a fellowship in rheumatology at Hospital for Joint Disease, New York University Langone Medical Center (1999-2001).
Dr. Azar treats arthritis, systemic lupus erythematosus (SLE), psoriatic arthritis, fibromyalgia (FMS), dermatomyositis, osteoarthritis, back pain, raynaud’s disease, spondyloarthropathies, autoimmune disease, polymyositis, osteoporosis, metabolic bone disease, sicca syndrome, scleroderma, rheumatoid arthritis, and connective tissue disease. She is a member of the American College of Rheumatology and American College of Physicians. She has been published in numerous journals, including Journal of Clinical RheumatologyArthritis & Rheumatism, and Journal of Immunology.
When did you first decide to become a physician? Why?
Medicine was really the only career that I ever entertained. Specifically, from the age of five, that’s what is was going to be. My father was a psychiatrist and that certainly impacted me and influenced my decision to become a doctor. As I grew older, the eagerness to have the knowledge to actually “help people” became my motivation. This never subsided and the charge to heal was entrenched.
How/why did you choose the medical school you attended?
I applied for medical school in 1991—about 10 schools was the norm then with a similar spread as now: the reaches and the safeties and everything in between. I was at Wellesley undergrad but grew up in Pennsylvania and these geographic experiences informed my choices. I was accepted first at Hershey (my state school) then Tufts for a combined MD/MPH program. Was thrilled with the latter and happy to stay in Boston, then got the call thatwould change my life: I was accepted to Cornell in NYC. It was one of those rare times in life when you “just know.” For many reasons and on many different levels it was the right school for me (reputation plus location). This almost got derailed with my acceptance at Hopkins—this was a torturous decision. How could I decline a school with this kind of reputation? Two very salient reasons emerged: 1) Hopkins did not work on a pass/fail system but rather, had a typical grading system and 2) it was just a bit too close to my hometown and I really felt like I would be taking a step backward. The reasons we do things are often driven by logic; but I think equally often, there is a visceral motivation that can’t be ignored.
What surprised you the most about your medical studies?
How hard medical school was compared to undergrad school. I distinctly remember being told by my premed advisor that I would have to work substantially harder in medical school than in college, which I found fascinating really, because I was very studious at Wellesley. Most of us will tell the students now that it is really the sheer volume of material that needs to get taught in four years that accounts for most of the challenge. The curriculum and professors, like any higher education, account for this as well but to a lesser degree, in my opinion.
Why did you decide to specialize in rheumatology?
Immunology was always of interest to me; it made logical sense, I loved learning about it and found it an incredibly elegant system. What I usually tell people, and this is true, is that it is a phenomenally interesting field; the inpatient work is very different from the outpatient, there is a nice balance between procedural work (i.e. injections) and cerebral exercise. And lastly, the patient population is very heterogeneous (it is not all older people with arthritis) so you engage people from all walks of life. There is a small skew toward young females as well (think autoimmune disease) and this is particularly rewarding for me.
If you had to do it all over again, would you still become a rheumatologist? Why or why not?
In a heartbeat I would do rheumatology again for all of the reasons previously stated. It has been the most rewarding field. I am in full time private practice but the opportunities for basic science, translational and clinical research are far reaching. In my experience, it has been a female friendly and highly respected field.
Has being a rheumatologist met your expectations? Please explain.
Unequivocally yes: I have established wonderful relationships with my patients, I have saved lives, I have helped couples realize their dream of starting a family, and I have continued to learn and grow as a physician.
What do you like most about being a rheumatologist?
Because we have to really know internal medicine (our diseases can and do affect almost every organ system), we have a very broad fund of knowledge that we keep adding to.
What do you like least about being a rheumatologist?
Some of the soft tissue rheumatology can be very challenging; remember that there are physicians who specialize in distinct areas of the body (e.g. shoulder, spine, knee, foot and ankle), and we are often expected (and we expect from ourselves) to be an expert at everything.
Describe a typical day at work—walk me through a day in your shoes.
Important point for this one is that I am 14+ years into practice, so this day is very different than when I first started (then it was five full, exhausting days with a ton of inpatient work and lots of call). Currently, I see patients Tuesday through Thursday; I get into the office at 8:15 a.m. and start seeing patients at 8:40 a.m. I do 20 minute follow-ups and allot an hour for new patients. I will typically see anywhere from eight to 12 patients per day, depending on the number of follow-ups. I work during lunch. The afternoon is all the other part of doctoring that we all have to do—check labs, radiology studies, write consult letters, deal with insurance company authorization requests, call back patients or email with them in their electronic medical record. I usually leave the office at 5 p.m. Additionally, during the academic year, I teach at the medical school every Tuesday from 3 to 5 p.m. and interview for the medical school on Wednesday afternoons. On many mornings, as the NBC News Medical Contributor, I am at the studio by 6:30 a .m. for a segment before going to the office. When there is a lot of breaking medical news (Ebola, flu, measles) I am back and forth to NBC multiple times a day.
On average, how many hours a week do you work? How many hours of sleep do you get per night? How many weeks of vacation do you take annually?
I work about 25 to 28 hours per week (just the doctoring, the media work adds a significant number of hours to that). I sleep about six to seven hours per night (not good enough). I take two weeks of vacation every year but can take days when needed, because I have an established practice and a fair amount of flexibility at my institution and my productivity isn’t sacrificed.
If you have family, do you feel you have enough time to spend with them? Why or why not? Definitely: after my first child, I went from five to four days and when I had my second I went down to three days. We also moved to the suburbs at this point so I had every incentive to try and make it work in three days. I should note that this is the time I began communicating with my patients via email in order to avail myself to them on the days I wasn’t in the office. I work a lot remotely: answering calls, prescribing meds, reviewing studies, etc. But I can take my kids to school and pick them up, and when they were younger, we had the days together. It is worth every effort if your situation allows.
How do you balance work and your life outside of work?
This is something I talk about often because I have experienced from friends in other fields that don’t have the kind of flexibility that I have in healthcare. These women were lawyers, ad execs, in public relations, bankers. Many of these fields are all or nothing for working moms, but healthcare, in my opinion, has far and away the most built-in flexibility of any career I have come across. That’s number one. Then, when I’ve been told how lucky I am that I “only work three days,” I quickly remind people that luck was the last thing that got my here. (By the time I had my first child, I was four or five years into my practice so I had the credibility to create a more flexible schedule).
Do you feel you are adequately compensated in your field? Please explain.
That’s a bit of a loaded question because I think generally the non-invasive internal medicine subspecialties are not high paying fields. I certainly feel compensated enoughbut this issue has so many layers: my salary is very much controlled by the reimbursements our hospital gets from the insurance industry. I am by no means overly-versed in this, but we understand that if reimbursements go down across the board, we will see that in our paychecks. Medicine is not the field to go into if your goal is to “make money” in the proverbial sense. That’s not why any of us really does it.
If you took out educational loans, is/was paying them back a strain? Please explain.
I was lucky enough to only have a year and half of loans to repay; I am still paying though at the tail end (I graduated in 1996). I felt it much more early on. There is a pretty high cost of practice though: loans, malpractice, DEA and license renewal, board certification and recertification, CME courses. If you are part of a faculty practice, especially at an academic medical center, some of that cost gets absorbed by the practice. It’s much harder when you’re a solo practitioner and own your practice.
In your position now, knowing what you do, what would you say to yourself back when you started your medical career?
You chose very, very well.
What information/advice do you wish you had known prior to medical school?
I think most of us say this, but probably how to manage the financial part of this career. We are notoriously poor at this, as article after article can attest.
From your perspective, what is the biggest problem in health care today? Please explain.
Again, likely redundant, but the complexity of the insurance system with the number of plans, pharmacy benefits, specialty pharmacies, approvals, authorizations, peer-to-peers, denials, and on and on… between problems systemically married to human error, it is sometimes a disaster to just get one drug approved for one patient. The time and the resources it can take to do something really quite trivial is mind numbing.
Where do you see rheumatology in five years?
Exploding even more than it was five years ago: bigger translational research with more biologics and probably more immunotherapy like we are seeing in oncology. It could really change the landscape for us.
What types of outreach/volunteer work do you do, if any?
I really don’t have time for anything other than my kids, my patients, my faculty responsibilities and NBC.
What’s your final piece of advice for students interested in pursuing a career in rheumatology?
Try to do electives, shadow us, get involved in some research. It could be bench or clinical, it doesn’t matter, anything to start seeing what’s out there and learning the language. Truthfully, you really don’t know what it’s going to be like until you start practicing (even fellowship is a slightly artificial world). Choose a field that feels right.